Chapter 46 Rena l and Urologic Problems 1155

Renal and urologic disorders encompass a wide spectrum of clini­

cal problems. The diverse causes of these disorders may involve

infectious, immunologic, obstructive, metabolic, collagen-vascular,

traumatic, congenital, neoplastic, and neurologic mechanisms.

This chapter discusses specific disorders of the kidneys, ureters,

bladder, and urethra. Acute renal failure and chronic kidney dis­

ease are discussed in Chapter 47. Female reproductive problems

are discussed in Chapter 54. Male genitourinary problems are dis­

cussed in Chapter 55.

Infectious and Inflammatory Disorders of the Urinary System

URINARY TRACT INFECTION Urinary tract infections (UTIs) are the second most common bac­

terial disease and the most common bacterial infection in women,

with at least one-third of women developing a UTI before the age

of 24. During their lifetime, more than half of women will have a

UTI, and up to 50% of these will have another infection within a

year. 1 Pregnant women are at increased risk for UTIs. UTIs com­

plicate up to 20% of pregnancies and are responsible for 10% of

all antepartum admissions. 2 UTIs account for more than 8 million

office visits per year and are associated with direct costs of $1.8

billion. More than 100,000 people are hospitalized annually be­

cause of UTIs. More than 15% of patients who develop gram-

negative bacteremia die, and one third of these cases are caused by

bacterial infections originating in the urinary tract . 1 , 3

Inflammation of the urinary tract may be attributable to a vari­

ety of disorders, but bacterial infection is by far the most com­

mon. 1 The bladder and its contents are free from bacteria in the

majority of healthy persons. Nevertheless, a minority of otherwise

healthy individuals, including many sexually active, young adult

women and older women and men, have some bacteria colonizing

the bladder. This condition is called asymptomatic bacteriuria and

does not justify screening or treatment except in pregnant women. 4

In contrast, an infection of the urinary system is diagnosed when

bacterial invasion of the urinary tract occurs.

Escherichia coli (Table 46-1) is the most common pathogen

causing a UTI, and is primarily seen in women. Bacterial counts of

10 5 colony-forming units per milliliter (CFU/ml) or higher typi­

cally indicate a clinically significant UTI. However, counts as low

as 10 2 to 10 3 CFU/ml in a person with signs and symptoms are

indicative of UTI. Although fungal and parasitic infections may

also cause UTIs, they are uncommon. UTIs from these causes are

sometimes observed in patients who are immunosuppressed, have

diabetes mellitus, or have undergone multiple courses of antibiotic

therapy. They also may be seen in persons living in or having

traveled to certain third-world countries.

Classification Several classification systems can be used for UTIs. 1 ' 3 For example,

a UTI can be broadly classified as an upper or lower UTI according

to its location within the urinary system (Fig. 46-1). Infection of the

upper urinary tract (involving the renal parenchyma, pelvis, and

ureters) typically causes fever, chills, and flank pain, whereas a UTI

confined to the lower urinary tract does not usually have systemic

manifestations. Specific terms are used to further delineate the loca­

tion of a UTI or inflammation. For example, pyelonephritis implies

TABLE 46-1 Common Microorganisms Causing Urinary Tract Infections

Escherichia coli' Pseudomonas Enterococcus Staphylococcus Klebsiella Serratia Enterobacter Candida albicans^ Proteus

*Causes about 80% of cases in persons who do not have urinary tract structural abnormalities or calculi. fUsually seen in patients who have received broad-spectrum antimicrobial antibiot­ics and have an indwelling catheter.

CULTURAL AND ETHNIC HEALTH DISPARITIES

Urologic Disorders

Urinary tract calculi are more common among whites than

African Americans.

• Jewish men have a high incidence of uric acid stones.

•* Bladder cancer has a higher incidence among white men than

African American men.

• In all ethnic groups, bladder cancer affects men about 3 times

more often than women.

• Prostate cancer has a higher prevalence in African American men

than white men.

« Urinary incontinence is underreported because culturally it is seen

as a social hygiene problem causing patient embarrassment.

inflammation (usually due to infection) of the renal parenchyma and

collecting system, cystitis indicates inflammation of the bladder

wall, and urethritis means inflammation of the urethra. Urosepsis is a UTI that has spread into the systemic circulation and is a life-

threatening condition requiring emergency treatment.

Classifying a UTI as complicated or uncomplicated is also use­

ful. 1 ' 3 Uncomplicated infections are those that occur in an other­

wise normal urinary tract and usually only involve the bladder. 2

Complicated infections include those with coexisting presence of

obstruction, stones, or catheters; existing diabetes or neurologic

diseases; pregnancy-induced changes; or an infection that is recur­

rent. The individual with a complicated infection is at risk for py­

elonephritis, urosepsis, and renal damage.

UTIs can also be classified according to their natural history.

An initial infection (sometimes called a first or isolated infection)

refers to an uncomplicated UTI in a person who has never had an

infection or experiences one that is remote from any previous UTI

(usually separated by a period of years). In contrast, a recurrent

UTI is a reinfection caused by a second pathogen in a person who

experienced a previous infection that was successfully eradicated.

If a recurrent UTI occurs because the original infection is not ade­

quately eradicated, it is classified as unresolved bacteriuria or bac­

terial persistence. Unresolved bacteriuria occurs when bacteria are

initially resistant to the antibiotic used to treat an infection, when

the antibiotic agent fails to achieve adequate concentrations in the

urine or bloodstream to kill bacteria, or when the drug is discon­

tinued before the underlying bacteriuria is completely eradicated.

Bacterial persistence also may occur when bacteria develop resis­

tance to the antibiotic agent selected for treatment or when a for­

eign body in the urinary system serves as a harbor or anchor allow­

ing bacteria to survive despite appropriate therapy. 3 , 5

Predisposing Factors to Urinary Tract Infections

FIG. 46-1 Sites of infectious processes in the urinary tract.

Etiology and Pathophysiology The urinary tract above the urethra is normally sterile. Several

mechanical and physiologic defense mechanisms assist in main­

taining sterility and preventing UTIs. These defenses include

normal voiding with complete emptying of the bladder, uretero­

vesical junction competence, and peristaltic activity that propels

urine toward the bladder. Antibacterial characteristics of urine

are maintained by an acidic pH ( < 6 . 0 ) , high urea concentration,

and abundant glycoproteins that interfere with the growth of

bacteria. An alteration in any of these defense mechanisms in­

creases the risk of contracting a UTI. Table 46-2 lists predispos­

ing factors to UTIs .

Menopause also appears to be a factor in the incidence of UTI

in women. Before menopause, glycogen-rich epithelial cells and

the normal bacterial flora Lactobacillus keep the vaginal pH acidic

(3.5 to 4.5). This acidic environment helps to prevent the over­

growth of organisms that usually only proliferate in a pH above

4.5. In postmenopausal women, lower estrogen levels cause vagi­

nal atrophy, a decrease in vaginal lactobacilli, and an increase in

vaginal pH. This leads to an overgrowth of other organisms, spe­

cifically E. coli, and increases susceptibility to UTIs. Giving

women low-dose intravaginal estrogen replacement acidifies the

vagina and may be effective in treating recurrent UTI . 6

The organisms that usually cause UTIs are introduced via the

ascending route from the urethra and originate in the perineum.

Other less common routes are via the bloodstream or lymphatic

system. Most infections are due to gram-negative bacilli normally

found in the gastrointestinal (GI) tract, although gram-positive or­

ganisms such as streptococci, enterococci, and Staphylococcus

saprophyticus can also cause urinary infections. A common factor

contributing to ascending infection is urologic instrumentation

(e.g., catheterization, cystoscopic examinations). Instrumentation

allows bacteria that are normally present at the opening of the ure­

thra to enter the urethra or bladder. Sexual intercourse promotes

TABLE 46-2

Factors Increasing Urinary Stasis • Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture,

BPH) • Extrinsic obstruction (tumor, fibrosis compressing urinary tract) • Urinary retention (including neurogenic bladder and low bladder

wall compliance) • Renal impairment

Foreign Bodies • Urinary tract calculi • Catheters (indwelling, external condom catheter, ureteral stent,

nephrostomy tube, intermittent catheterization) • Urinary tract instrumentation (cystoscopy, urodynamics)

Anatomic Factors • Congenital defects leading to obstruction or urinary stasis • Fistula (abnormal opening) exposing urinary stream to skin, vagina,

or fecal stream • Shorter female urethra and colonization from normal vaginal flora • Obesity

Factors Compromising Immune Response • Aging • Human immunodeficiency virus infection • Diabetes mellitus

Functional Disorders • Constipation • Voiding dysfunction with detrusor sphincter dyssynergia

Other Factors • Pregnancy • Hypoestrogenic state • Multiple sex partners (women) • Use of spermicidal agents or contraceptive diaphragm (women) • Poor personal hygiene

BPH, Benign prostatic hyperplasia.

"milking" of bacteria from the vagina and perineum and may

cause minor urethral trauma that predisposes women to UTIs.

Rarely do UTIs result from a hematogenous route, where

blood-borne bacteria secondarily invade the kidneys, ureters, or

bladder from elsewhere in the body. For a kidney infection to occur

from hematogenous transmission, there must be prior injury to the

urinary tract, such as obstruction of the ureter, damage caused by

stones, or renal scars.

An important source of UTIs is hospital-acquired, or nosoco­

mial, infections, which account for 3 1 % of all nosocomial infec­

tions. 7 The cause of nosocomial infection is often E. coli and, less

frequently, Pseudomonas organisms. Catheter-acquired urinary

tract infections (CAUTIs) are the most common nosocomial infec­

tions and are caused by development of bacterial biofilms that are

found on the inner surface of the catheter. 8 Most often these infec­

tions are underrecognized and undertreated, leading to complica­

tions such as renal abscesses, arthritis, epididymitis, periurethral

gland infections, and bacteremia.

Clinical Manifestat ions

Lower urinary tract symptoms (LUTS) are experienced in patients

who have UTIs of the upper urinary tracts, as well as those con­

fined to the lower tract. 9 These symptoms are related to either

bladder storage or bladder emptying. These symptoms are defined

in Table 46-3.

Chapter 46 Renal and Urologic Prob lems 1157

TABLE 46-3 Lower Urinary Tract Symptoms (LUTS)

Emptying Symptoms Weak urinary stream Hesitancy—difficulty starting the urine stream resulting in a delay

between initiation of urination by relaxation of the urethral sphincter and when urine stream actually begins.

Intermittency—interruption of the urinary stream while voiding. Postvoid dribbling—urine loss after completion of voiding. Urinary retention or incomplete emptying—inability to empty urine

from the bladder, which can be caused by atonic bladder or obstruction of the urethra. Can be acute or chronic.

Dysuria—difficulty voiding. Pain on urination

Storage Symptoms Urinary frequency—an abnormally frequent (usually >8 times in a

24-hr period) desire to void, often of only small quantities (e.g., less than 200 ml).

Urgency—a sudden, strong or intense desire to void immediately, usually accompanied by frequency.

Incontinence—involuntary or unwanted loss or leakage of urine. Nocturia—waking up 2 or more times at night because of the need or

urge to void. Nocturnal enuresis—complaint of loss of urine during sleep. In

children, it is called bedwetting.

These symptoms include dysuria, frequent urination (more of­

ten than every 2 hours), urgency, and suprapubic discomfort or

pressure. The urine may contain grossly visible blood (hematuria)

or sediment, giving it a cloudy appearance. Flank pain, chills, and

the presence of a fever indicate an infection involving the upper

urinary tract (pyelonephritis). It is important to remember that

these symptoms, considered characteristic of a UTI, are often ab­

sent in older adults. Older adults tend to experience nonlocalized

abdominal discomfort rather than dysuria and suprapubic pa in . 1 0

In addition, they may present with cognitive impairment or gener­

alized clinical deterioration. Because older adults are less likely to

experience a fever with a UTI, the value of body temperature as an

indicator of a UTI is unreliable. Patients over age 80 years may

experience a slight decline in temperature. People with significant

bacteriuria may have no symptoms or may have nonspecific symp­

toms such as fatigue or anorexia.

Multiple factors may produce LUTS similar to a UTI. For ex­

ample, patients with bladder tumors or those receiving intravesical

chemotherapy or pelvic radiation usually experience urinary fre­

quency, urgency, and dysuria. Interstitial cystitis, a chronic inflam­

matory condition of unknown etiology, also produces urinary

symptoms that are sometimes confused with a UTI. (Interstitial

cystitis is discussed later in this chapter.)

Diagnostic Studies

Dipstick urinalysis should be obtained initially to identify the pres­

ence of nitrites (indicating bacteriuria), white blood cells (WBCs),

and leukocyte esterase (an enzyme present in WBCs indicating

pyuria). These findings can be confirmed by microscopic urinaly­

s is . 1 1 Following confirmation of bacteriuria and pyuria, a urine

culture may be obtained. A urine culture is indicated in compli­

cated or nosocomial UTIs, persistent bacteria, or frequently recur­

ring UTIs (more than two to three episodes per year). Urine also

may be cultured when the infection is unresponsive to empiric

therapy or the diagnosis is questionable.

A voided midstream technique yielding a clean-catch urine

sample is preferred for obtaining a urine culture in most circum­

stances. For women, this is done by spreading the labia and wiping

the periurethral area from front to back using a moistened, clean

gauze sponge (no antiseptic is used as it could contaminate the

specimen and cause false positives), keeping the labia spread and

collecting the specimen 1 to 2 seconds after voiding starts. For

men, the glans penis is wiped around the urethra. The specimen is

collected 1 to 2 seconds after voiding begins.

Urine should be refrigerated immediately on collection and

should be cultured within 24 hours of refrigeration. However, a

specimen obtained by catheterization or suprapubic needle aspira­

tion provides more accurate results and may be necessary when an

adequate clean-catch specimen cannot be readily obtained.

A urine culture is accompanied by sensitivity testing to deter­

mine the bacteria's susceptibility to a variety of antibiotic drugs.

The results of this test allow the health care provider to select an

antibiotic known to be capable of destroying the bacterial strain

producing a UTI in a specific patient.

Imaging studies of the urinary tract are indicated in selected

cases. For example, an intravenous pyelogram (IVP) or abdominal

computed tomography (CT) scan may be obtained when obstruc­

tion of the urinary system is suspected of causing a UTI. In pa­

tients with recurrent UTIs, renal ultrasound is the preferred urinary

tract imaging technique because it is noninvasive, easy to perform,

and relatively inexpensive.

Studies have shown that patients with symptoms can effectively

diagnose their own UTIs and self-initiate treatments with the same

success rate as physicians . 2 , 3

Collaborative Care and Drug Therapy

Once a UTI has been diagnosed, appropriate antimicrobial therapy

is initiated. An antibiotic may be selected based on the health care

provider's best judgment (empiric therapy) or the results of sensi­

tivity testing. The collaborative care and drug therapy of cystitis

are summarized in Table 46-4. Uncomplicated cystitis can be

treated by a short-term course of antibiotics, typically for 1 to 3

days. In contrast, complicated UTIs require longer term treatment,

lasting 7 to 14 days or even longer . 2 5 Because many residents of

long-term care facilities (approximately 30% to 50%), especially

females, have chronic asymptomatic bacteriuria, the research-

based literature suggests treating only symptomatic UTIs. There­

fore continued bacteriuria without clinical symptoms does not

warrant repeat or continued antibiotic therapy. 7

Trimethoprim/sulfamethoxazole (TMP/SMX) or nitrofurantoin

(Macrodantin) is often used to empirically treat uncomplicated or

initial UTIs. TMP/SMX has the advantages of being relatively in­

expensive and being taken twice daily. The disadvantage is that

E. coli resistance to TMP/SMX is an increasing problem across the

United States. Nitrofurantoin is normally given 3 to 4 times daily,

but a long-acting preparation (Macrobid) is available that is taken

twice daily. However, long-term use of nitrofurantoin can result in

pulmonary fibrosis and neuropathies. 3 Ampicillin and amoxicillin

are not frequently selected when empirically treating a noncompli­

cated UTI because they must be administered 3 to 4 times daily. In

addition to these agents, the fluoroquinolones (including cipro­

floxacin [Cipro], levofloxacin [Levaquin], norfloxacin [Noroxin],

ofloxacin [Floxin], and gatifloxacin [Tequin]) may be used to treat

complicated UTIs. In patients with UTIs secondary to fungi, am­

photericin or fluconazole are preferred therapy.

1158 Sec t ion 9 Problems of Urinary Funct ion

TABLE 46-4

COLLABORATIVE CARE Urinary Tract Infection

Diagnostic History and physical examination Urinalysis—obtain a midstream voided "clean-catch" urine specimen Urine for culture and sensitivity (if indicated) Imaging studies of urinary tract (e.g., IVR cystoscopy) (if indicated)

Collaborative Therapy Uncomplicated UTI Antibiotic: trimethoprim-sulfamethoxazole (TMP-SMX) (Bactrim,

Septra), or trimethoprim alone in patients with sulfa allergy; nitrofurantoin (Macrodantin, Macrobid)

Adequate fluid intake Urinary analgesic: phenazopyridine (Pyridium) or combination agent

(e.g., Urised)

Counseling about risk of recurrence and reduction of risk factors

Recurrent, Uncomplicated UTI Repeat urinalysis and consider urine culture and sensitivity testing Antibiotic: 3- to 5-day treatment regimen of TMP-SMX, nitrofurantoin Sensitivity-guided antibiotic (ampicillin, amoxicillin, first-generation

cephalosporin, fluoroquinolone) Consider postcoital antibiotic prophylaxis (TMP-SMX, nitrofurantoin,

cephalexin) Advise on pre- and postcoital voiding Consideration of 3- to 6-month trial of (suppressive) prophylactic

antibiotics Adequate fluid intake Cranberry or lingonberry juice (200-750 ml or equivalent tablets daily) Urinary analgesic such as phenazopyridine (Pyridium) or combination

agent (e.g., Urised) Counseling about risk of recurrence and reduction of risk factors Imaging study of urinary tract in selected cases

IVP, Intravenous pyelogram; UTI, urinary tract infection.

Drug Alert - Nitrofurantoin (Furadantin, Macrodantin) • Avoid sunlight; use sunscreen, wear protective clothing. • Notify health care provider if fever, chills, cough, chest pain, dyspnea,

rash, or numbness or tingling of fingers or toes develops.

A number of over-the-counter (OTC) or prescription drugs

may be used in combination with antibiotic agents to relieve the

discomfort associated with a UTI. Phenazopyridine (Pyridium) is

an OTC drug that provides a soothing effect on the urinary tract

mucosa. It also stains the urine a reddish orange that may be

mistaken for blood in the urine, and it may permanently stain

underclothing. Although this drug is typically effective in reliev­

ing the transient acute discomfort associated with a UTI, patients

should be advised to avoid long-term use of phenazopyridine

because it can produce hemolytic anemia. Combination agents

such as Urised (methenamine, phenyl salicylate, methylene blue,

benzoic acid, atropine, and hyoscyamine) may also be used to

relieve the symptoms associated with a UTI. The patient taking a

combination agent such as Urised should be advised that prepa­

rations containing methylene blue are expected to tint the urine

blue or green.

Prophylactic or suppressive antibiotics are sometimes adminis­

tered to patients who experience repeated UTIs. A low dose of

TMP/SMX, nitrofurantoin, or another antibiotic may be adminis­

tered on a daily basis in an attempt to prevent recurring UTIs, or a

single dose may be taken before an event likely to provoke a UTI,

such as before having sexual intercourse. Although suppressive

therapy is often effective on a short-term basis, this strategy is

Are Prophylactic Antibiotics Effective for Jrinary Tract Infection?

In women (P), is long-term prophylactic antibiotic use (I) more

effective than placebo (C) in preventing recurrent urinary tract

infections (O)? ) n a "1 L I r- - J

• Systematic review of randomized controlled trials (RCTs)

j • 10 RCTs (n = 430 women) comparing antibiotic use for 6 to

12 months against a placebo for recurrent urinary tract infec­

tions (UTI).

• Recurrence is defined as three or more UTI episodes during a

12-month period. j

• Antibiotics reduced the number of UTI recurrences in pre- and I postmenopausal women with recurrent UTI.

« ' Antibiotic group had higher incidence of side effects, including

vaginal itching, skin rash, and nausea.

Conclusions Prophylactic antibiotic administration in women who experience

recurrent UTIs reduces recurrence.

Implications for Nursing Practice • Patient treatment preference should be considered when weigh­

ing the discomfort of recurrent UTIs and the adverse effects of

prophylactic antibiotics,

• UTI prophylaxis for longer than 12 months has not been studied.

Reference for Evidence Albert X, Huertas I, Pereiro I, et al: Antibiotics for preventing recurrent urinary tract infection in non-pregnant women, Cochrane Database Syst Rev 3, 2004.

PICO: P, Patient population of interest; /, intervention or area of interest; C, com­parison of interest or comparison group; O, outcome(s) of interest (see p. 6).

limited because of the risk of antibiotic resistance, which ulti­

mately leads to breakthrough infections with increasingly virulent

pa thogens . 1 , 3

NURSING MANAGEMENT URINARY TRACT INFECTION

• Nursing Assessment

Subjective and objective data that should be obtained from a pa­

tient with a UTI are presented in Table 46-5.

• Nursing Diagnoses

Nursing diagnoses for the patient with a UTI may include, but are

not limited to, those presented in NCP 46-1 .

• Planning

The overall goals are that the patient with a UTI will have (1) relief

from bothersome LUTS, (2) prevention of upper urinary tract in­

volvement, and (3) prevention of recurrence.

• Nursing Implementation

Health Promotion. Health promotion measures include recog­

nizing individuals who are at risk for a UTI. Debilitated persons,

older adults, patients with underlying diseases (e.g., cancer, human

immunodeficiency virus [HIV], or diabetes mellitus) that compro­

mise host immune responses, and patients treated with immuno-

Chapter 46 Rena l a n d U r o l o g i c Problems 1159

TABLE 46-5

NURSING ASSESSMENT Urinary Tract Infection

Subjective Data Important Health Information Past health history: Previous urinary tract infections; urinary calculi,

stasis, reflux, strictures, or retention; neurogenic bladder; pregnancy; benign prostatic hyperplasia; sexually transmitted disease; bladder cancer

Medications: Use of antibiotics, anticholinergics, antispasmodics Surgery or other treatments: Recent urologic instrumentation

(catheterization, cystoscopy, surgery)

Functional Health Patterns Health perception-health management: Urinary hygiene practices;

lassitude, malaise Nutritional-metabolic: Nausea, vomiting, and anorexia; chills Elimination: Urinary frequency, urgency, hesitancy; dysuria,

nocturia Cognitive-perceptual: Suprapubic or low back pain, costovertebral

tenderness; bladder spasms, dysuria, burning on urination Sexuality-reproductive: Multiple sex partners (women), use of spermici­

dal agents or contraceptive diaphragm (women)

Objective Data General

Fever, chills, overall clinical deterioration can be seen in elderly

Urinary

Hematuria; cloudy, foul-smelling urine; tender, enlarged kidney

Possible Findings Leukocytosis; urinalysis positive for bacteria, pyuria, RBCs, and WBCs;

positive urine culture; IVP, CT scan, ultrasound, voiding cystourethrogram, and cystoscopy demonstrating abnormalities of urinary tract

CT, Computed tomography; IVP, intravenous pyelogram; RBCs, red blood cells; WBCs, white blood cells.

suppressive drugs or corticosteroids are at high risk for UTIs. Es­

pecially for these individuals, health promotion activities can help

decrease the frequency of infections and promote early detection

of infection. Health promotion activities include teaching preven­

tive measures such as (1) emptying the bladder regularly and

completely, (2) evacuating the bowel regularly, (3) wiping the

perineal area from front to back after urination and defecation, and

(4) drinking an adequate amount of liquid each day. The recom­

mended daily liquid intake for the ambulatory adult is approxi­

mately 15 ml per pound of body weight per day. Thus a 150-pound

person would require 2250 ml each day. Because the person will

obtain approximately 20% of this fluid from food, this leaves 1800

ml obtained by drinking, or just over seven 8-ounce glasses of

fluid. Daily intake of cranberry or lingonberry juice or cranberry

essence tablets may reduce the risk of UTIs . 1 2 It is thought that

enzymes found in cranberries inhibit attachment of urinary patho­

gens (especially E. coli) to the bladder epithelium. Suppressive

antibiotics are not generally recommended to prevent UTIs, but it

is important to teach the patient to seek early treatment once symp­

toms occur.

The nurse can play a major role in the prevention of nosocomial

infections. Avoidance of unnecessary catheterization and early re­

moval of indwelling catheters are the most effective means for re­

ducing nosocomial UTIs. All patients undergoing instrumentation

of the urinary tract are at risk for developing a nosocomial UTI.

Aseptic technique must always be followed during these proce­

dures. Washing hands before and after contact with each patient

and wearing gloves for care involving the urinary system are espe­

cially important. When a catheter has been inserted, special mea­

sures must be employed as explained in the section on urethral

catheterization later in this chapter.

Routine and thorough perineal hygiene is important for all hos­

pitalized patients, especially when a bedpan is used, following a

bowel movement, and/or if fecal incontinence is present. Inconti­

nent episodes should be avoided by answering the call light

quickly or offering the bedpan or urinal at frequent intervals to the

bedridden patient.

Acute Intervention. Acute intervention for a patient with a UTI

includes ensuring adequate fluid intake if it is not contraindicated.

It is sometimes difficult to get the patient to maintain an adequate

fluid intake because the person may think it will worsen the dis­

comfort and frequency associated with a UTI. The patient needs to

be told that fluids will increase frequency of urination at first but

will also dilute the urine, making the bladder less irritable. Fluids

will help flush out bacteria before they have a chance to colonize

in the bladder. Caffeine, alcohol, citrus juices, chocolate, and

highly spiced foods or beverages should be avoided because they

are potential bladder irritants.

Application of local heat to the suprapubic area or lower back

may relieve the discomfort associated with a UTI. The patient can

be advised to apply a heating pad (turned to its lowest setting)

against the back or suprapubic area. A warm shower or sitting in a

tub of warm water filled above the waist can also be effective in

providing temporary relief.

The patient should be instructed about the prescribed drug

therapy, including side effects. The nurse should emphasize the

importance of taking the full course of antibiotics. Often pa­

tients stop antibiotic therapy once symptoms disappear. This

practice can lead to inadequate treatment and recurrence of in­

fection or to bacterial resistance to antibiotics. Sometimes a

second drug or a reduced dose of drug is ordered after the initial

course to suppress bacterial growth in patients susceptible to re­

current UTI . The patient should be instructed to watch for any

changes in the color or consistency of the urine and a decrease

in or cessation of symptoms as a sign of the effectiveness of

therapy. The patient should be counseled that (1) persistence of

bothersome LUTS beyond the antibiotic treatment course,

(2) the onset of flank pain, or (3) fever should be reported

promptly to a health care provider.

Ambulatory and Home Care. Home care for the patient with a

UTI should emphasize the patient's compliance with the drug

regimen. The nurse's responsibility is to teach the patient about the

need for ongoing care (Table 46-6). This includes taking antimi­

crobial drugs as ordered, maintaining adequate daily fluid intake,

regular voiding (approximately every 3 to 4 hours), urinating be­

fore and after intercourse, and temporarily discontinuing the use of

a diaphragm (if used).

The patient must understand the need for follow-up care if symp­

toms do not resolve, worsen, or return once treatment is completed.

Recurrent symptoms because of bacterial persistence or inadequate

treatment typically occur within 1 to 2 weeks after completion of

therapy. If the patient has been compliant with treatment, a relapse

indicates the need for further evaluation.

• Evaluation

The expected outcomes for the patient with a UTI are presented in

NCP 46-1 .

1160 Sec t ion 9 P rob lems of Urinary Funct ion

NURSING CARE PLAN 46-1

11 Patient with a Urinary Tract Infection NURSING DIAGNOSIS Impaired urinary elimination related to effects of urinary tract infection ( U T 1 ) as evidenced by pain and burning on

urination; flank, suprapubic, and/or lower back pain; urgency; frequency; nocturia; or hematuria

PATIENT GOALS l. Experiences normal urinary elimination patterns 2. Reports relief of bothersome urinary tract symptoms

Urinary Elimination Pain with urination Burning with urination _ Urinary frequency Urgency with urination. Nocturia Visible blood in urine _

Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

Urinary Elimination Management • Monitor urinary elimination, including frequency, consistency, odor, volume, and color,

to evaluate elimination status. • Obtain midstream voided specimen for culture and sensitivity (as appropriate) to

determine pathogen causing UTI or to monitor effectiveness of treatment. « Teach patient to drink eight ounces of liquid with meals, between meals, and in early

evening to prevent dehydration, relieve bladder irritability, and decrease bacterial colonization.

Pain Management Perform a comprehensive assessment of pain to include location, characteristics, onset/ duration, frequency, quality, intensity or severity, and precipitating factors to establish history and baseline pain level.

• Provide the patient optimal pain relief with prescribed analgesics (such as phenazopyridine [Pyridium]) or combination agents (e.g., Urised) to promote comfort.

• Teach the use of nonpharmacologic techniques (e.g., heating pad to suprapubic area or lower back, warm showers) along with other relief measures to supplement pain medication and increase pain relief.

NURSING DIAGNOSIS Ineffective therapeutic regimen management related to lack of knowledge regarding treatment regimen and preven­tion of recurrent infections as evidenced by verbalization of desire to manage treatment of illness and prevent recurrence

PATIENT COALS l. Verbalizes knowledge of treatment regimen 2. Expresses intent to carry out treatment regimen

OUTGO

Knowledge: Treatment Regimen * Description of specific disease process _

Description of rationale for treatment regimen .

* Description of self-care responsibilities for ongoing treatment

» Description of expected effects of treatment Description of prescribed medications _

Measurement Scale 1 ~ None 2 = Limited 3 — Moderate 4 = Substantial 5 == Extensive

11 i\ iVH i! 11M111 ii11 \n Mil\l\ MifiU^tISm3Wlfmmm!\ Teaching: Disease Process '"• Appraise patient's current level of knowledge related to specific disease process to plan

individualized teaching, o Explain pathophysiology of the disease and how it relates to anatomy and physiology. * Describe rationale behind management/therapy/treatment recommendations to promote

compliance with treatment. ' Describe possible chronic complications to emphasize the need for completion of

treatment.

Teaching: Prescribed Medication * Instruct patient on the purpose and action of each medication. * Instruct patient on possible adverse effects of each medication so patient can identify

problems. * Instruct patient on appropriate actions to take if side effects occur to prevent serious

problems.

t o . , : ; : - • , . ; - 3 !

Potential Complications " Anticipate potential for urosepsis in patients at

risk. Report deviations from acceptable parameters.

» Carry out appropriate medical and nursing interventions.

Urosepsis (bacteriuria and bacteremia) related to systemic extension of UTI Monitor vital signs and for changes in mental status in patients at risk (immunocompro­mised, elderly, those with frequent urinary system instrumentation or anatomic abnormalities) to detect inadequate tissue perfusion.

* Report abnormalities such as hyper- or hypothermia; decreasing blood pressure; rapid pulse and respirations; and warm, flushed skin as indicators of septic shock resulting from urosepsis.

* Monitor platelet levels and coagulation function tests because alterations indicate bleeding tendencies.

C h a p t e r 46 Rena l and Urologic Problems 1161

TABLE 46-6

PATIENT AND FAMILY TEACHING GUIDE Urinary Tract Infection

The following are important to teach to the patient with a UTI to prevent recurrence: 1. Explain importance of taking all antibiotics as prescribed.

Symptoms may improve after 1 to 2 days of therapy, but organisms may still be present.

2. Instruct the patient on appropriate hygiene, including the following: • Careful cleansing of perineal region by separating the labia

when cleansing • Wiping from front to back after urinating • Cleansing with warm soapy water after each bowel movement

3. Explain the importance of emptying the bladder before and after sexual intercourse.

4. Instruct the patient to urinate regularly, approximately every 3 to 4 hours during the day.

5. Instruct the patient about the need to maintain adequate fluid intake.

6. Instruct the patient to avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area.

7. Advise the patient to report symptoms or signs of recurrent UTI (e.g., fever, cloudy urine, pain on urination, urgency, frequency).

8. Suggest possible use of unsweetened cranberry juice 8 oz three times a day or extract tablets 300 to 400 mg/day for UTI prevention.

UTI, Urinary tract infection.

ACUTE PYELONEPHRITIS

Etiology and Pathophysiology Pyelonephritis is an inflammation of the renal parenchyma (Fig.

46-2) and collecting system (including the renal pelvis). The most

common cause is bacterial infection, but fungi, protozoa, or vi­

ruses sometimes infect the kidney.

Urosepsis is a systemic infection arising from a urologic

source. Its prompt diagnosis and effective treatment are critical

because it can lead to septic shock and death in 15% of cases un­

less promptly eradicated. Septic shock is the outcome of unre­

solved bacteremia involving a gram-negative organism. 1 3 (Septic

shock is discussed in Chapter 67.)

Pyelonephritis usually begins with colonization and infection

of the lower urinary tract via the ascending urethral route. Bacteria

normally found in the intestinal tract, such as E. coli, Proteus,

Klebsiella, or Enterobacter species, frequently cause pyelonephri­

tis. A preexisting factor is often present, such as vesicoureteral re­

flux (retrograde or backward movement of urine from lower to up­

per urinary tract) or dysfunction of lower urinary tract function

such as obstruction from benign prostatic hyperplasia (BPH), a

stricture, or urinary stone. In residents of long-term care facilities,

urinary tract catheterization and the use of indwelling catheters is

a common cause of pyelonephritis and urosepsis.

Acute pyelonephritis commonly starts in the renal medulla and

spreads to the adjacent cortex. One of the most important risk fac­

tors for acute pyelonephritis is pregnancy-induced physiologic

changes in the urinary system. 2 Recurring episodes of pyelone­

phritis, especially in the presence of obstructive abnormalities, can

lead to a scarred, poorly functioning kidney and a condition called

chronic pyelonephritis.

Clinical Manifestations and Diagnostic Studies The clinical manifestations of acute pyelonephritis vary from mild

fatigue to the sudden onset of chills, fever, vomiting, malaise, flank

pain, and the LUTS characteristic of cystitis, including dysuria,

FIG. 46-2 Acute pyelonephritis. Cortical surface shows grayish white a rea ; :"

inf lammation and abscess formation.

urinary urgency, and frequency. Costovertebral tenderness (costo­

vertebral angle [CVA] pain) is typically present on the affected

side. The clinical manifestations usually subside within a few

days, even without specific therapy, but bacteriuria and pyuria usu­

ally persist.

Urinalysis shows pyuria, bacteriuria, and varying degrees of

hematuria. W B C casts may be found in the urine, indicating in­

volvement of the renal parenchyma. A complete blood count will

show leukocytosis and a shift to the left with an increase in imma­

ture neutrophils (bands). Urine cultures must be obtained when

pyelonephritis is suspected. In patients with more severe illness

who are hospitalized, blood cultures are also obtained.

Imaging studies, such as an IVP or CT scan, requiring intrave­

nous (IV) injection of contrast materials are usually not obtained

in the early stages of pyelonephritis to prevent the possible spread

of infection. Alternatively, ultrasonography of the urinary system

may be obtained to identify anatomic abnormalities, hydronephro­

sis, renal abscesses, or the presence of an obstructing stone. Imag­

ing studies are also used to assess for complications of pyelone­

phritis such as impaired renal function, scarring, chronic

pyelonephritis, or abscesses.

Urosepsis is characterized by bacteriuria and bacteremia (pres­

ence of bacteria in blood). If bacteremia is a possibility, close ob­

servation and vital sign monitoring are essential. Prompt recogni­

tion and treatment of septic shock may prevent irreversible dar. a i

or death.

Collaborative Care and Drug Therapy The diagnostic tests and collaborative therapy of acute pyelone­

phritis are summarized in Table 46-7. Patients with severe infec­

tions or complicating factors such as nausea and vomiting with

dehydration require hospital admission.

The patient with mild symptoms may be treated as an outpatient

with antibiotics for 14 to 21 days (see Table 46-7). Parenteral antibi­otics are often given initially in the hospital to rapidly estabiis

serum and urinary drug levels. When initial treatment resoh es acute

symptoms and the patient is able to tolerate oral fluids and drugs, the

person may be discharged on a regimen of oral antibiotics for an ad­

ditional 14 to 21 days. Symptoms and signs typically improve or re­

solve within 48 to 72 hours after starting therapy. 1 4

Relapses may be treated with a 6-week course of antibiotics

Reinfections may be treated as individual episodes of disease or