ATI Med-Surg: Chapter 61: Infections of the Renal and Urinary System

Urinary tract infection (UTI)

A urinary tract infection (UTI) refers to any portion of the lower urinary tract (ureters, bladder, urethra, prostate). This includes the following: ◯ Cystitis ◯ Urethritis ◯ Prostatitis An upper UTI refers to conditions such as pyelonephritis (inflammation of the kidney pelvis). ● UTIs are caused by Enterobacteriaceae micro-organisms (klebsiella, proteus), pseudomonas, Staphylococcus saprophyticus, and most commonly, Escherichia coli. ● Untreated UTIs may lead to pyelonephritis and urosepsis, which can cause septic shock and death.

Acute pyelonephritis

Active bacterial infection that can cause the following: ◯ Interstitial inflammation ◯ Tubular cell necrosis ◯ Abscess formation in the capsule, cortex, or medulla ◯ Temporarily altered kidney function (this rarely progresses to chronic kidney disease)

Chronic pyelonephritis

Result of repeated infections that cause progressive inflammation and scarring. ◯ This can result in the thickening of the calyces and postinflammatory fibrosis with permanent renal tissue scarring. ◯ It is more common with obstructions, urinary anomaly, and vesicoureteral urine reflux. ◯ Reflux of urine occurs at the junction where the ureter connects to the bladder.

Urinary system

There are three components to the urinary system: the ureter, bladder, and urethra. The goal of the urinary system is to promote optimal kidney function. Two infections that affect the renal and urinary system are urinary tract infections, and pyelonephritis.

Complications of UTI

Urethral obstruction, pyelonephritis, chronic kidney disease, urosepsis, septic shock, and death

Diagnostic Procedures of UTI

■ Cystoscopy is used for complicated UTIs. ■ Cystourethroscopy to detect strictures, calculi, tumors, cystitis. ■ Computed tomography (CT) scan to detect pyelonephritis. ■ Ultrasonography to detect cysts, tumors, calculi, and abscesses. ■ Transrectal ultrasonography to detect prostate and bladder conditions in males.

Risk Factors of UTI- Female Gender

■ Short urethra predisposes women to UTIs ■ Close proximity of the urethra to the rectu ■ Decreased estrogen in aging women promotes atrophy of the urethral opening toward the rectum (increases the risk of urosepsis in women) ■ Sexual intercourse ■ Frequent use of feminine hygiene sprays, tampons, sanitary napkins, and spermicidal jellies ■ Pregnancy ■ Poorly fitted diaphragm ■ Hormonal influences within the vaginal flora ■ Synthetic underwear and pantyhose ■ Wet bathing suits ■ Frequent submersion into baths or hot tubs

Laboratory Tests of UTI

■ Urinalysis and urine culture and sensitivity ☐ Nursing Actions ◯ Instruct the client regarding proper technique for the collection of a clean-catch urine specimen. ◯ Collect catheterized urine specimens using sterile technique. ☐ Expected findings include the following: ◯ Bacteria, sediment, white blood cells (WBC), and red blood cells (RBC) ◯ Positive leukocyte esterase and nitrates (68% to 88% positive results indicates UTI) ■ WBC count and differential if urosepsis is suspected ☐ White blood cell count at or above 10,000/uL with a shift to the left, indicating an increased number of immature cells (neutrophils) in response to infection ■ Rule out sexually transmitted infections, which can cause symptoms of a UTI. ☐ Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex can cause acute urethritis. ☐ Trichomonas or candida can cause acute vaginal infections.

Pyelonephritis

● Pyelonephritis is an infection and inflammation of the kidney pelvis, calyces, and medulla. The infection usually begins in the lower urinary tract with organisms ascending into the kidney pelvis. ● Escherichia coli organisms are the cause of most acute cases of pyelonephritis. ● Repeated infections create scarring that changes the blood flow to the kidney, glomerulus, and tubular structure. ● Filtration, reabsorption, and secretion are impaired, which results in a decrease in renal function.

Complications of Chronic Pyelonephritis

● Septic shock (hypotension, tachycardia, fever) due to bacterial organism entering the blood stream. ● Chronic kidney disease (elevated BUN, creatinine, electrolytes) from inflammation and infection that causes fibrosis of the kidney pelvis and calyx, scarring, and changes in the blood vessels and the glomerular and tubular filtration system. ● Hypertension (related to fluid and sodium retention) indicating chronic kidney disease caused by destruction of the filtration system of the kidney due to infection.

Diagnostic Procedures for Pyleonephritis

◯ An x-ray of the kidneys, ureters, and bladder (KUB) may demonstrate calculi or structural abnormalities. ◯ Ultrasonography to detect cysts, tumors, calculi, and abscesses. ◯ Gallium scan - a nuclear medicine test that uses injectable radioactive dye to visualize organs, glands, bones, and blood vessels that have infection and inflammation. ◯ Intravenous pyelogram (IVP) may demonstrate calculi, structural, or vascular abnormalities.

Nursing Care (Nonsurgical) for Pyleonephritis

◯ Assess/Monitor ■ Nutritional status ■ Intake and output ■ Fluid and electrolyte balance ■ Pain status ■ Temperature ■ The onset, quality, duration, and severity of the pain ◯ Increase fluid intake to 2 to 3 L/day unless contraindicated. ◯ Administer antipyretic, such as acetaminophen (Tylenol), as needed for fever and opioid analgesics for pain associated with pyelonephritis and following procedures. ◯ Provide emotional support. ◯ Assist with personal hygiene.

Subjective Data of Pyleonephritis

◯ Chills ◯ Colicky-type abdominal pain ◯ Nausea ◯ Malaise, fatigue ◯ Burning, urgency, and frequency with urination ◯ Costovertebral tenderness

Client Education for Pyleonephritis

◯ Educate the client regarding adequate nutritional status. ◯ Encourage the client to drink at least 3 L of fluids daily unless otherwise indicated by the provider. ◯ Instruct the client to take medications as prescribed. ◯ Instruct the client to notify the provider if acute onset of pain occurs or a fever is present. ◯ Encourage the client and family to express their fears and anxiety related to the disease. ◯ Encourage the client to take rest periods as needed from activity.

Objective Data for UTI

◯ Fever ◯ Vomiting ◯ Voiding in small amounts ◯ Nocturia ◯ Urethral discharge ◯ Cloudy or foul-smelling urine ◯ Older Adult Clinical Manifestation of UTI ■ Mental confusion ■ Incontinence ■ Loss of appetite ■ Nocturia and dysuria ■ Hypotension, tachycardia, tachypnea, and fever (signs of urosepsis)

Objective Data of Pyleonephritis

◯ Fever, tachycardia, tachypnea, hypertension ◯ Flank and back pain ◯ Vomiting ◯ Nocturia ◯ Inability to concentrate urine or conserve sodium (chronic pyelonephritis) ◯ Asymptomatic bacteremia

Medications for UTI

◯ Fluoroquinolones (ciprofloxacin, norfloxacin, levofloxacin), nitrofurantoin (Macrodantin, Furadantin, Macrobid), trimethoprim, or sulfonamides (Bactrim or Septra) are antibiotics used to treat urinary infections by directly killing bacteria and inhibiting bacterial reproduction. ■ Penicillins and cephalosporins are administered less frequently because the medication is less effective and tolerated. ■ Nitrofurantoin is an antibacterial medication where therapeutic levels are achieved in the urine only. ■ Nursing Considerations ☐ If sulfonamide is prescribed, ask the client about allergy to sulfa. ■ Client Education ☐ Educate the client regarding the need to take all of the prescribed antibiotics even if symptoms subside. ☐ Encourage the client to take the medication with food. ◯ Phenazopyridine (Pyridium, Urogesic) is bladder analgesic used to treat UTIs. ■ Nursing Considerations ☐ The medication will not treat the infection, but it will help relieve bladder discomfort. ☐ Inform the client that the medication will turn urine orange. ■ Client Education ☐ Encourage the client to take the medication with food.

Nursing Care (Surgical) for Pyleonephritis

◯ Includes all the above information. ◯ Assess the dressings and incision. ◯ Balance rest and activities. ◯ Instruct on monitoring signs of infection. ◯ Instruct on the role of nutritious meals and adequate fluid intake.

Risk Factors of UTI

◯ Indwelling urinary catheters (significant source of infection in clients who are hospitalized) ◯ Stool incontinence ◯ Bladder distention ◯ Urinary conditions (anomalies, stasis, calculi, residual urine) ◯ Possible genetic links ◯ Disease (diabetes mellitus)

Surgical Interventions for Pyleonephritis

◯ Inform the client of the purpose of the surgery and expected outcomes. ◯ Intravenous antibiotics and analgesics are usually administered for each procedure. ◯ Pyelolithotomy - This is the removal of a large stone from the kidney that causes infections and blocks the flow of urine from the kidney. ◯ Nephrectomy - This is the removal of the kidney when all procedures to clear the client of infection were unsuccessful. ◯ Ureteroplasty - This is done to repair or revise the ureter and can involve reimplantation of the ureter in the bladder wall to preserve the function of the kidney and eliminate infection.

Client Education of UTI

◯ Instruct the client to drink at least 3 L of fluid daily. ◯ Instruct the client to bathe daily to promote good body hygiene. ◯ Advise the client to empty bladder every 3 to 4 hr instead of waiting until the bladder is completely full. ◯ Advise the client to urinate before and after intercourse. ◯ Advise the client to drink cranberry juice to decrease the risk of infection. ■ The compound in cranberries may stop certain bacteria from adhering to the mucosa of the urinary tract. ■ Clients who have chronic cystitis should avoid cranberry juice, which irritates the bladder. ◯ Advise the client to empty the bladder as soon as there is an urgency to void. ◯ Instruct female clients to: ■ Wipe the perineal area from front to back. ■ Avoid using bubble baths, and feminine products and toilet paper containing perfumes. ■ Avoid sitting in wet bathing suits. ■ Avoid wearing pantyhose with slacks or tight clothing.

Subjective Data of UTI

◯ Lower back or lower abdominal discomfort and tenderness over the bladder area ◯ Nausea ◯ Urinary frequency and urgency ◯ Dysuria, bladder cramping, spasms ◯ Feeling of incomplete bladder emptying or retention of urine ◯ Perineal itching ◯ Hematuria (red-tinged, smoky, coffee-colored urine) ◯ Pyuria (greater than 4 WBC in urine sample)

Risk Factors of pyleonephritis

◯ Men over 65 years of age who have prostatitis and hypertrophy of the prostate ◯ Chronic urinary stone disorders (stones harbor bacteria) ◯ Spinal cord injury (clients have a higher incidence of reflux) ◯ Pregnancy ◯ Congenital malformations ◯ Bladder tumors ◯ Chronic illness (diabetes mellitus, hypertension, chronic cystitis) ◯ Urine pH increases, becoming more alkaline, in older adult clients and promotes bacterial growth. ◯ Incomplete bladder emptying is more common among older adult clients. ◯ Older adult clients may exhibit gastrointestinal or pulmonary symptoms instead of febrile responses because an older adult client's temperature may vary at a lower than normal state. ■ Causes are inadequate diet, loss of adipose tissue, lack of exercise, and reduction in the client's thermoregulator.

Risk Factors of UTI: Older Adults

◯ Older adult clients have an increased risk of bacteremia, sepsis, and shock. ■ Incomplete bladder emptying caused by an enlarged prostate or prostatitis in males ■ Bladder prolapse in females ■ Inability to empty bladder (neurogenic bladder) as a result of a stroke or Parkinson's disease ■ Fecal incontinence with poor perineal hygiene ■ Hypoestrogen in females affecting the mucosa of the vagina and urethra, causing bacteria to adhere to the mucosal surface ■ Renal complications increase due to decreased number of functioning nephrons and fluid intake

Medications for Pyelonephritis

◯ Opioid analgesics (opioid agonists), morphine sulfate, and morphine for moderate to severe pain ◯ Antibiotics ■ Mild to moderate pyelonephritis treated at home for 14 days with the following: ☐ Anti-infective - trimethoprim (Primsol), sulfamethoxazole/trimethoprim (Bactrim, Septra) ☐ Quinolone antibiotic - ciprofloxacin (Cipro), levofloxacin (Levaquin) ■ Severe pyelonephritis treated in the hospital for 24 to 48 hr with IV medication: ☐ Quinolone antibiotic - ciprofloxacin (Cipro) ☐ Cephalosporin antibiotic - ceftriaxone (Cefizox), ceftazidime (Fortaz) ☐ Aminopenicillin antibiotic - ampicillin (Principen), ampicillin/sulbactam (Unasyn) ☐ Aminoglycoside antibiotic - gentamicin, tobramycin (Tobrex), amikacin (Amikin)

Nursing Care of UTI

◯ Promote fluid intake up to 3 L daily. ◯ Consult with the provider regarding prescribed fluid restrictions if needed. ◯ Administer antibiotic medications as prescribed. ◯ Encourage clients to urinate every 3 to 4 hr instead of waiting until the bladder is completely full. ◯ Recommend warm sitz bath two or three times a day to provide comfort. ◯ Encourage clients to bathe daily to promote good body hygiene. ◯ Avoid the use of indwelling catheters if possible. This reduces the risk for infection.

Laboratory Tests for Pyleonephritis

◯ Urinalysis and urine culture and sensitivity same as for a UTI (positive leukocyte esterase and nitrites, WBCs, and bacteria). ◯ WBC count and differential: Same as for a UTI. ◯ Blood cultures will be positive for the presence of bacteria if a systemic infection is present. ◯ Serum creatinine and blood urea nitrogen (BUN) are elevated during acute episodes and consistently elevated with chronic infection. ◯ C-reactive protein is elevated during exacerbating inflammatory processes of the kidneys. ■ Erythrocyte sedimentation rate (ESR) is elevated during acute or chronic inflammation.