Chapter 55 management of patient with urinary

Cancer of the bladder

Cancer of the urinary bladder is more common in people older than 55 years. It is the third most common cancer in men and the eleventh most common in women (National Cancer Institute [NCI], 2016). Bladder cancer is a leading cause of death, accounting for more than 15,000 deaths in the United States annually (NCI, 2016). Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder. Chart 55-13 SELECTED RISK FACTORS Bladder Cancer Certain genetic mutations including: HRAS mutation (Costello syndrome, Facio-cutaneous-skeletal syndrome). Rb1 mutation. PTEN/MMAC1 mutation (Cowden syndrome). NAT2 slow acetylator phenotype. GSTM1 null phenotype. Exposure to arsenic Occupational exposure to chemicals in processed paint, dye, metal, and petroleum products Positive family history of bladder cancer Pelvic radiation therapy or treatment for other cancers Tobacco use, cigarette smoking in particular Adapted from National Cancer Institute (NCI). (2016). Bladder cancer treatment (PDQ®)-Health professional version. Retrieved 12/13/2016 at: www.cancer.gov/types/bladder/hp/bladder-treatment-pdq#section/all Tobacco use continues to be a leading risk factor for all urinary tract cancers. People who smoke develop bladder cancer twice as often as those who do not smoke (NCI, 2016) (see Chart 55-13). Clinical Manifestations Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Visible, painless hematuria is the most common symptom of bladder cancer. Infection of the urinary tract is a common complication, producing frequency and urgency. However, any alteration in voiding or change in the urine may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis. Assessment and Diagnostic Findings The diagnostic evaluation includes ureteroscopy (the mainstay of diagnosis), excretory urography, CT and MRI scans, ultrasonography, and bimanual examination with the patient anesthetized. Biopsies of the tumor and adjacent mucosa are the definitive diagnostic procedures (NCI, 2016). Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells. Cytologic examination of fresh urine and saline bladder washings provide information about the prognosis and staging, especially for patients at high risk for recurrence of primary bladder tumors. See Chapter 15 for more information on cancer grading and staging. Medical Management Treatment of bladder cancer depends on the grade of the tumor (the degree of cellular differentiation), the stage of tumor growth (the degree of local invasion and the presence or absence of metastasis) (NCI, 2016). The patient's age and physical, mental, and emotional status are considered when determining treatment modalities. Surgical Management Transurethral resection or fulguration (cauterization) may be performed for simple papillomas (benign epithelial tumors). These procedures (described in more detail in Chapter 59) eradicate the tumors through surgical incision or electrical current with the use of instruments inserted through the urethra. After this bladder-sparing surgery, intravesical administration of bacille Calmette-Guérin (BCG) is the treatment of choice. BCG Live (TheraCys) is an attenuated live strain of Mycobacterium bovis, the causative agent in tuberculosis; treatment is recommended for a minimum of 1 year (NCI, 2016). The exact action of BCG is unknown, but it is thought to produce a local inflammatory and a systemic immunologic response. Management of superficial bladder cancers presents a challenge because there are usually widespread abnormalities in the bladder mucosa. The entire lining of the urinary tract, or urothelium, is at risk because carcinomatous changes can occur in the mucosa of the bladder, kidney pelvis, ureter, and urethra. A simple cystectomy or a radical cystectomy is performed for invasive or multifocal bladder cancer. Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent perivesical tissues. In women, radical cystectomy involves removal of the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of pelvic lymph nodes. Removal of the bladder requires a urinary diversion procedure, which is described later in this chapter. Although radical cystectomy remains the standard of care for invasive bladder cancer in the United States, clinical trials are exploring trimodality therapy—transurethral resection of the bladder tumor, radiation, and chemotherapy—in an effort to spare patients the need for cystectomy (NCI, 2016). This approach to transitional cell bladder cancer mandates lifelong surveillance with periodic cystoscopy. Although most patients respond completely and their bladders remain free from invasive relapse, one fourth develop a relapse of noninvasive disease. This may be managed with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that a late cystectomy may be required. Pharmacologic Therapy Chemotherapy with a combination of methotrexate, 5-fluorouracil, vinblastine (Velban), doxorubicin (Adriamycin), and cisplatin (Platinol) has been effective in producing partial remission of transitional cell carcinoma of the bladder in some patients. IV chemotherapy may be accompanied by radiation therapy (NCI, 2016). Topical chemotherapy (intravesical chemotherapy or instillation of antineoplastic agents into the bladder, resulting in contact of the agent with the bladder wall) is considered when there is a high risk of recurrence, when cancer in situ is present, or when tumor resection has been incomplete. Topical chemotherapy delivers a high concentration of medication (thiotepa [Thioplex], doxorubicin, mitomycin [Mutamycin], and BCG Live) to the tumor to promote tumor destruction. Bladder cancer may also be treated by direct infusion of the cytotoxic agent through the bladder's arterial blood supply to achieve a higher concentration of the chemotherapeutic agent with fewer systemic toxic effects (NCI, 2016). BCG Live is now considered the most predominant and conservative intravesical agent for recurrent bladder cancer, especially superficial transitional cell carcinoma, because it is an immunotherapeutic agent that enhances the body's immune response to cancer. BCG Live has a 43% advantage in preventing tumor recurrence, a significantly better rate than the 16% to 21% advantage of intravesical chemotherapy. In addition, BCG Live is particularly effective in the treatment of carcinoma in situ, eradicating it in more than 80% of cases. In contrast to intravesical chemotherapy, BCG Live has also been shown to decrease the risk of tumor progression. Although BCG Live treatment is the current standard of care, this treatment fails or is not tolerated in a significant proportion of patients (Askeland, Newton, O'Donnell, et al., 2012). The optimal course of BCG Live appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months for tumors that do not respond. In high-risk cancers, maintenance BCG Live given in a 3-week course at 6, 12, 18, and 24 months may limit recurrence and prevent progression. However, the adverse effects associated with this prolonged therapy may limit its widespread applicability. The patient is allowed to eat and drink before the instillation procedure. Once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. At the end of the procedure, the patient is encouraged to void and to drink liberal amounts of fluid to flush the medication from the bladder. Radiation Therapy Radiation of the tumor may be performed preoperatively to reduce microextension of the neoplasm and viability of tumor cells, thus decreasing the chances that the cancer may recur in the immediate area or spread through the circulatory or lymphatic systems. Radiation therapy is also used in combination with surgery or to control the disease in patients with inoperable tumors. For more advanced bladder cancer or for patients with intractable hematuria (especially after radiation therapy), a large, water-filled balloon placed in the bladder produces tumor necrosis by reducing the blood supply of the bladder wall (hydrostatic therapy). The instillation of formalin, phenol, or silver nitrate relieves hematuria and strangury (slow and painful discharge of urine) in some patients. (Hinkle 1637-1639) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Continent urinary diversions

Continent Ileal Urinary Reservoir (Indiana Pouch) The most common continent urinary diversion is the Indiana pouch, created for the patient whose bladder is removed or no longer functions. The Indiana pouch uses a segment of the ileum and cecum to form the reservoir for urine (see Fig. 55-8A). The ureters are tunneled through the muscular bands of the intestinal pouch and anastomosed. The reservoir is made continent by narrowing the efferent portion of the ileum and sewing the terminal ileum to the subcutaneous tissue, forming a continent stoma flush with the skin. The pouch is sewn to the anterior abdominal wall around a cecostomy tube. Urine collects in the pouch until a catheter is inserted and the urine is drained. The pouch must be drained at regular intervals by a catheter to prevent absorption of metabolic waste products from the urine, reflux of urine to the ureters, and UTI. Postoperative nursing care of the patient with a continent ileal urinary pouch is similar to nursing care of the patient with an ileal conduit. However, these patients usually have additional drainage tubes (cecostomy catheter from the pouch, stoma catheter exiting from the stoma, ureteral stents, and Penrose drain, as well as a urethral catheter). All drainage tubes must be carefully monitored for patency and amount and type of drainage. In the immediate postoperative period, the cecostomy tube is irrigated two or three times daily to remove mucus and prevent blockage. Other variations of continent urinary reservoirs are used occasionally (Crawshaw, Williams, & Woodhouse, 2014). With these methods, the pouch must be drained at regular intervals by inserting a catheter. For the procedural guidelines for draining a continent ileostomy (Kock pouch), go to thepoint.lww.com/Brunner14e. Ureterosigmoidostomy Ureterosigmoidostomy, another form of continent urinary diversion, is a transplantation of the ureters into the sigmoid colon, allowing urine to flow through the colon and out the rectum (see Fig. 55-8B). It is usually performed in patients who have had extensive pelvic irradiation, previous small bowel resection, or coexisting small bowel disease. After surgery, voiding occurs from the rectum (for life), and an adjustment in lifestyle will be necessary because of urinary frequency. Drainage has a consistency equivalent to watery diarrhea, and the patient has some degree of nocturia. Patients usually need to plan activities around the frequent need to urinate, which in turn may affect the patient's social life. However, patients have the advantage of urinary control without having to wear an external appliance. Nursing Management In addition to the usual preoperative regimen, the patient may be placed on a liquid diet for several days preoperatively to reduce residue in the colon. Antibiotic agents (neomycin, kanamycin) are given to disinfect the bowel. Ureterosigmoidostomy requires a competent anal sphincter, adequate kidney function, and active renal peristalsis. The degree of anal sphincter control may be determined by assessing the patient's ability to retain enemas. The postoperative regimen initially includes placing a catheter in the rectum to drain the urine and prevent reflux of urine into the ureters and kidneys. The tube is taped to the buttocks, and special skin care is given around the anus to prevent excoriation. Irrigations of the rectal tube may be prescribed, but force is never used because of the danger of introducing bacteria into the newly implanted ureters. Monitoring Fluid and Electrolytes In ureterosigmoidostomy, larger areas of the bowel mucosa are exposed to urine and electrolyte reabsorption. As a result, electrolyte imbalance and acidosis may occur. Potassium and magnesium in the urine may cause diarrhea. Fluid and electrolyte balance is maintained in the immediate postoperative period by closely monitoring the serum electrolyte levels and administering appropriate IV fluids. Acidosis may be prevented by placing the patient on a low-chloride diet supplemented with sodium potassium citrate. The patient should be instructed never to wait longer than 2 to 3 hours before emptying urine from the intestine. This keeps rectal pressure low and minimizes the absorption of urinary constituents from the colon. It is essential to educate the patient about the symptoms of UTI: fever, flank pain, urgency, and frequency. Retraining the Anal Sphincter After the rectal catheter is removed, the patient learns to control the anal sphincter through special sphincter exercises. At first, urination is frequent. With reassurance and encouragement and the passage of time, the patient gains greater control and learns to differentiate between the need to void and the need to defecate. Promoting Dietary Measures Specific dietary instructions include avoidance of gas-forming foods (flatus can cause stress incontinence and offensive odors). Other ways to avoid gas are to avoid chewing gum, smoking, and any other activity that involves swallowing air. Salt intake may be restricted to prevent hyperchloremic acidosis. Potassium intake is increased through foods and medication because potassium may be lost in acidosis. Monitoring and Managing Potential Complications Pyelonephritis (upper UTI) due to reflux of bacteria from the colon is fairly common. Long-term antibiotic therapy may be prescribed to prevent infection. A late complication is adenocarcinoma of the sigmoid colon, possibly from cellular changes due to exposure of the colonic mucosa to urine. Urinary carcinogens promote late malignant transformation of the colon after a ureterosigmoidostomy, warranting lifelong medical follow-up. (Hinkle 1642-1643) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Urinary diversions

Urinary diversion procedures are performed to divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin. These procedures are primarily performed when a bladder tumor necessitates cystectomy (NCI, 2016). Urinary diversion has also been used in managing pelvic malignancy, birth defects, strictures, trauma to the ureters and urethra, neurogenic bladder, chronic infection causing severe ureteral and kidney damage, and intractable interstitial cystitis. It may also be used as a last resort in managing incontinence. Controversy exists about the best method of establishing permanent diversion of the urinary tract. New techniques are frequently introduced in an effort to improve patient outcomes and quality of life. The age of the patient, condition of the bladder, body build, degree of obesity, degree of ureteral dilation, status of kidney function, and the patient's learning ability and willingness to participate in postoperative care are all taken into consideration when determining the appropriate surgical procedure. The outcome for a patient with a urinary diversion depends to a large degree on the location or position of the stoma, whether the drainage device (pouch or bag) establishes a watertight seal to the skin, and the patient's ability to manage the pouch and drainage apparatus (Rubenwolf, Hampel, Roos, et al., 2016). There are two types of urinary diversion. In a cutaneous urinary diversion, urine drains through an opening created in the abdominal wall and skin (see Fig. 55-7). In a continent urinary diversion, a portion of the intestine is used to create a new reservoir for urine (see Fig. 55-8A) (Hinkle 1639) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

urinary retention

Urinary retention is the inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (involuntary urine loss associated with overdistention of the bladder). Residual urine is urine that remains in the bladder after voiding. In a healthy adult younger than 60 years, complete bladder emptying should occur with each voiding. In adults older than 60 years, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying. Pathophysiology Urinary retention may result from diabetes, prostatic enlargement, urethral pathology (infection, tumor, calculus), trauma (pelvic injuries), pregnancy, or neurologic disorders (e.g., stroke, spinal cord injury, multiple sclerosis, or Parkinson disease). Some medications cause urinary retention either by inhibiting bladder contractility or by increasing bladder outlet resistance (Comerford, 2015). Assessment and Diagnostic Findings The assessment of a patient for urinary retention is multifaceted because the signs and symptoms are challenging to detect. The following questions serve as a guide in assessment: What was the time of the last voiding, and how much urine was voided? Is the patient voiding small amounts of urine frequently? Is the patient dribbling urine? Does the patient complain of pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly.) Is the pelvic area rounded and swollen (could indicate urine retention and a distended bladder)? Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)? Are other indicators of urinary retention present, such as restlessness and agitation? Does a postvoid bladder ultrasound test reveal residual urine? The patient may verbalize an awareness of bladder fullness and a sensation of incomplete bladder emptying. Signs and symptoms of UTI (hematuria, urgency, frequency, and nocturia) may be present. A series of urodynamic studies (described in Chapter 53) may be performed to identify the type of bladder dysfunction and to aid in determining appropriate treatment. A voiding diary can be used to provide a written record of the amount of urine voided and the frequency of voiding. Postvoid residual urine may be assessed by using either straight catheterization or an ultrasound bladder scanner and is considered diagnostic of urinary retention. Normally, residual urine amounts to no more than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult (Weber & Kelley, 2014). Complications The retention of urine can lead to chronic infections that if unresolved predispose the patient to renal calculi (urolithiasis or nephrolithiasis), pyelonephritis, sepsis, or hydronephrosis. In addition, urine leakage can lead to perineal skin breakdown, especially if regular hygiene measures are neglected. Nursing Management Strategies are instituted to prevent overdistention of the bladder and to treat infection or correct obstruction. However, many complications can be prevented with careful assessment and appropriate nursing interventions. The nurse explains to the patient why normal voiding is not occurring and monitors urine output closely. The nurse also provides reassurance about the temporary nature of retention and successful management strategies. Promoting Urinary Elimination Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and body position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. If his condition allows, the male patient may stand beside the bed to use the urinal; most men find this position more comfortable and natural. Additional measures include applying warmth to relax the sphincters (i.e., sitz baths, warm compresses to the perineum, showers), giving the patient hot caffeine free beverage and offering encouragement and reassurance. Simple trigger techniques, such as turning on the water faucet while the patient is trying to void, may also be used. Other examples of trigger techniques are stroking the abdomen or inner thighs, tapping above the pubic area, and dipping the patient's hands in warm water. After surgery or childbirth, prescribed analgesic agents should be given because pain in the perineal area can make voiding difficult. A combination of techniques may be necessary to initiate voiding. When the patient cannot void, bladder scanning is used to assess for distension, then straight catheterization (as prescribed) is used to prevent overdistention of the bladder (see later discussion of neurogenic bladder and catheterization). In the case of prostatic obstruction, attempts at catheterization (by the urologist) may not be successful, requiring insertion of a suprapubic catheter (catheter inserted through a small abdominal incision into the bladder). After urinary drainage is restored, bladder retraining is initiated for the patient who cannot void spontaneously. Promoting Home, Community-Based, and Transitional Care In addition to the strategies listed for promoting urinary continence found in Chart 55-9, modifications to the home environment can provide simple and effective ways to assist in treating urinary incontinence and retention. For example, the patient may need to remove obstacles, such as throw rugs or other objects, to provide easy, safe access to the bathroom. Other modifications that the nurse may recommend include installing support bars in the bathroom; placing a bedside commode, bedpan, or urinal within easy reach; leaving lights on in the bedroom and bathroom; and wearing clothing that is easy to remove quickly. (Hinkle 1627-1628) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Urolothiasis and nephrolithiasis

Urolithiasis and nephrolithiasis refer to stones (calculi) in the urinary tract and kidney, respectively. Urinary stones predominantly occur in the third to fifth decades of life and affect men twice as often as women (Cunningham, Noble, Al-Modhefer, et al., 2016). Stones may develop in one or both kidneys and yearly episodes are increasing (Cunningham et al., 2016). Pathophysiology Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. Referred to as supersaturation, this depends on the amount of the substance, ionic strength, and pH of the urine. Stones may be found anywhere from the kidney to the bladder and may vary in size from minute granular deposits, called sand or gravel, to bladder stones as large as an orange. The different sites of calculi formation in the urinary tract are shown in Figure 55-5. Certain factors favor the formation of stones, including infection, urinary stasis, and periods of immobility, all of which slow kidney drainage and alter calcium metabolism (Grossman & Porth, 2014). In addition, increased calcium concentrations in the blood and urine promote precipitation of calcium and formation of stones (about 80% of all kidney stones are calcium based) (Cunningham et al., 2016). Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) may include the following: Hyperparathyroidism Renal tubular acidosis Cancers (e.g., leukemia, multiple myeloma) Dehydration Granulomatous diseases (e.g., sarcoidosis, tuberculosis), which may cause increased vitamin D production by the granulomatous tissue Excessive intake of vitamin D Excessive intake of milk and alkali Myeloproliferative diseases such as polycythemia vera, which produce an unusual proliferation of blood cells from the bone marrow Figure 55-5 • Examples of potential sites of calculi formation (urolithiasis) in the urinary tract. For patients with stones containing uric acid, struvite, or cystine, a thorough physical examination and metabolic workup are indicated because of associated disturbances contributing to the stone formation. Uric acid stones (5% to 10% of all stones) may be seen in patients with gout or myeloproliferative disorders. Struvite stones account for 15% of urinary calculi and form in persistently alkaline, ammonia-rich urine caused by the presence of urease-splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma species. Predisposing factors for struvite stones include neurogenic bladder, foreign bodies, and recurrent UTIs. Several conditions, as well as certain metabolic risk factors, predispose patients to stone formation. These include anatomic derangements such as polycystic kidney disease, horseshoe kidneys, chronic strictures, and medullary sponge disease. Urinary stone formation can occur in patients with inflammatory bowel disease and in those with an ileostomy or bowel resection because these patients absorb more oxalate. Medications known to cause stones in some patients include antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin (Comerford, 2015). However, in many patients, no cause may be found. Clinical Manifestations Signs and symptoms of stones in the urinary system depend on the presence of obstruction, infection, and edema. When stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter (Cunningham et al., 2016). Infection (pyelonephritis and UTI with chills, fever, and frequency) can be a contributing factor with struvite stones. Some stones cause few, if any, symptoms while slowly destroying the functional units (nephrons) of the kidney; others cause excruciating pain and discomfort. Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region. Hematuria is often present; pyuria may also be noted. Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testes in the male. If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting occur, the patient is having an episode of renal colic. Diarrhea and abdominal discomfort are due to renointestinal reflexes and the anatomic proximity of the kidneys to the stomach, pancreas, and large intestine. Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain that radiates down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Colic is mediated by prostaglandin E, a substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain. In general, the patient is able to pass stones 0.5 to 1 cm in diameter. Stones larger than 1 cm in diameter usually must be removed or fragmented (broken up by lithotripsy) so that they can be removed or passed spontaneously. Stones lodged in the bladder usually produce symptoms of irritation and may be associated with UTI and hematuria. If the stone obstructs the bladder neck, urinary retention occurs. If infection is associated with a stone, the condition is far more serious, with the potential for urosepsis developing. Assessment and Diagnostic Findings The diagnosis is confirmed by a noncontrast CT scan (Cunningham et al., 2016). Blood chemistries and a 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume may be part of the diagnostic workup. Dietary and medication histories and family history of kidney stones are obtained to identify factors predisposing the patient to the formation of stones. When stones are recovered (whether freely passed by the patient or removed through special procedures), chemical analysis is carried out to determine their composition. Stone analysis can provide a clear indication of the underlying disorder. For example, calcium oxalate or calcium phosphate stones usually indicate disorders of oxalate or calcium metabolism, whereas urate stones suggest a disturbance in uric acid metabolism (Cunningham et al., 2016). Medical Management The goals of management are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. The immediate objective of treatment of renal or ureteral colic is to relieve the pain until its cause can be eliminated. Opioid analgesic agents are given to prevent shock and syncope that may result from the excruciating pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating kidney stone pain because they provide specific pain relief (Cunningham et al., 2016). They also inhibit the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone. Generally, once the stone has passed, the pain is relieved. Hot baths or moist heat to the flank area may also be helpful. Unless the patient is vomiting or has heart failure or any other condition requiring fluid restriction, fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output. Nutritional Therapy Nutritional therapy plays an important role in preventing kidney stones (Cunningham et al., 2016) (see Chart 55-12). Fluid intake is the mainstay of most medical therapy for kidney stones. Unless fluids are contraindicated, patients with kidney stones should drink eight to ten 8-oz glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L/day is advisable. Calcium Stones Historically, patients with calcium-based kidney stones were recommended to restrict calcium in their diet. However, evidence has questioned this practice, except for patients with type II absorptive hypercalciuria (half of all patients with calcium stones), in whom stones are clearly the result of excess dietary calcium. Liberal fluid intake is encouraged. Medications such as ammonium chloride may be used, and if increased parathormone production (resulting in increased serum calcium levels in blood and urine) is a factor in the formation of stones, therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated parathormone levels (Cunningham et al., 2016). Uric Acid Stones For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited. Allopurinol (Zyloprim) may be prescribed to reduce serum uric acid levels and urinary uric acid excretion (Comerford, 2015). Chart 55-12 PATIENT EDUCATION Preventing Kidney Stones The nurse instructs the patient to: Avoid protein intake to decrease urinary excretion of calcium and uric acid. Limit sodium intake to 3-4 g/day. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys. Be aware that low-calcium diets are not generally recommended, except for true absorptive hypercalciuria. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent stones. Avoid intake of oxalate-containing foods (e.g., spinach, strawberries, rhubarb, tea, peanuts, wheat bran). Drink fluids (ideally water and one glass of cranberry juice per day) every 1-2 hours during the day. Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. Avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. Contact the primary provider at the first sign of a urinary tract infection. Cystine Stones A low-protein diet is prescribed, the urine is alkalinized, and fluid intake is increased. Oxalate Stones A dilute urine is maintained, and the intake of oxalate is limited. Many foods contain oxalate; however, only certain foods increase the urinary excretion of oxalate. These include spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran. Interventional Procedures If the stone does not pass spontaneously or if complications occur, common interventions include endoscopic or other procedures. For example, ureteroscopy, extracorporeal shock wave lithotripsy (ESWL), or endourologic (percutaneous) stone removal may be necessary. Ureteroscopy (see Fig. 55-6A) involves first visualizing the stone and then destroying it. Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones. A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent. Length of hospital stay is generally brief, and some patients can be treated as outpatients. ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney (see Fig. 55-6B). After the stones are fragmented to the size of grains of sand, the remnants of the stones are spontaneously voided. In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different intensity (a kidney stone), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces that are excreted in the urine. Discomfort from the multiple shocks may occur, although the shock waves usually do not cause damage to other tissue. The patient is observed for obstruction and infection resulting from blockage of the urinary tract by stone fragments. All urine is strained after the procedure; voided gravel or sand is sent to the laboratory for chemical analysis. Several treatments may be necessary to ensure disintegration of stones (Cunningham et al., 2016). Endourologic methods of stone removal (see Fig. 55-6C) may be used to extract kidney calculi that cannot be removed by other procedures. A percutaneous nephrostomy or a percutaneous nephrolithotomy (which are similar procedures) may be performed. A nephroscope is introduced through a percutaneous route into the renal parenchyma. Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. If the stone is too large to initially be removed, an ultrasound probe inserted through a nephrostomy tube is used to pulverize the stone. Small stone fragments and stone dust are then removed. Electrohydraulic lithotripsy is a similar method in which an electrical discharge is used to create a hydraulic shock wave to break up the stone. A probe is passed through the cystoscope, and the tip of the lithotriptor is placed near the stone. The strength of the discharge and pulse frequency can be varied. This procedure is performed under topical anesthesia. After the stone is extracted, the percutaneous nephrostomy tube is left in place for a time to ensure that the ureter is not obstructed by edema or blood clots. The most common complications are hemorrhage, infection, and urinary extravasation. After the tube is removed, the nephrostomy tract usually closes spontaneously. Chemolysis, stone dissolution using infusions of chemical solutions (e.g., alkylating agents, acidifying agents) for the purpose of dissolving the stone, is an alternative treatment sometimes used in patients who are at risk for complications with other types of therapy, who refuse to undergo other methods, or who have stones (struvite) that dissolve easily. A percutaneous nephrostomy is performed, and the warm chemical solution is allowed to flow continuously onto the stone. The solution exits the renal collecting system by means of the ureter or the nephrostomy tube. The pressure inside the renal pelvis is monitored during the procedure. Several of these treatment modalities may be used in combination to ensure removal of the stones. Surgical Management Surgical removal was the major mode of therapy before the advent of lithotripsy. However, today, surgery is performed in only 1% to 2% of patients (Cunningham et al., 2016). Surgical intervention is indicated if the stone does not respond to other forms of treatment. It may also be performed to correct anatomic abnormalities within the kidney to improve urinary drainage. If the stone is in the kidney, the surgery performed may be a nephrolithotomy (incision into the kidney with removal of the stone) or a nephrectomy, if the kidney is nonfunctional secondary to infection or hydronephrosis. Stones in the kidney pelvis are removed by a pyelolithotomy, those in the ureter by ureterolithotomy, and those in the bladder by cystotomy. If the stone is in the bladder, an instrument may be inserted through the urethra into the bladder, and the stone crushed. Such a procedure is called a cystolitholapaxy. Nursing management following kidney surgery is discussed in Chapter 54. NURSING PROCESS The Patient With Kidney Stones Assessment The patient with suspected kidney stones is assessed for pain and discomfort as well as associated symptoms, such as nausea, vomiting, diarrhea, and abdominal distention. The severity and location of pain are determined, along with any radiation of the pain. Nursing assessment also includes observing for signs and symptoms of UTI (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). The urine is inspected for blood and is strained for stones or gravel. p. 1634 p. 1635 Figure 55-6 • Methods of treating kidney stones. A. During ureteroscopy, which is used for removing small stones located in the ureter close to the bladder, a ureteroscope is inserted into the ureter to visualize the stone. The stone is then fragmented or captured and removed. B. Extracorporeal shock water lithotripsy is used for most symptomatic, nonpassable upper urinary stones. Electromagnetically generated shock waves are focused over the area of the kidney stone. The high-energy dry shock waves pass through the skin and fragment the stone. C. Percutaneous nephrolithotomy is used to treat larger stones. A percutaneous tract is formed, and a nephroscope is inserted through it. Then, the stone is extracted or pulverized. p. 1635 p. 1636 The history focuses on factors that predispose the patient to urinary tract stones or that may have precipitated the current episode of renal or ureteral colic. The patient's knowledge about kidney stones and measures to prevent their occurrence or recurrence is also assessed. Diagnosis NURSING DIAGNOSES Based on the assessment data, nursing diagnoses may include the following: Acute pain related to inflammation, obstruction, and abrasion of the urinary tract Deficient knowledge regarding prevention of recurrence of kidney stones COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Infection and urosepsis (from UTI and pyelonephritis) Obstruction of the urinary tract by a stone or edema with subsequent acute kidney injury Planning and Goals The major goals for the patient may include relief of pain and discomfort, prevention of recurrence of kidney stones, and absence of complications. Nursing Interventions RELIEVING PAIN Severe acute pain is often the presenting symptom of a patient with kidney and urinary calculi and requires immediate attention. Opioid analgesic agents (IV or intramuscular) may be prescribed and given to provide rapid relief along with an IV NSAID. The patient is encouraged and assisted to assume a position of comfort. If activity brings pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and an increase in severity is reported promptly to the primary provider so that relief can be provided and additional treatment initiated. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Increased fluid intake is encouraged to prevent dehydration and increase hydrostatic pressure within the urinary tract to promote passage of the stone. If the patient cannot take adequate fluids orally, IV fluids are prescribed. The total urine output and patterns of voiding are monitored. Ambulation is encouraged as a means of moving the stone through the urinary tract. All urine is strained because uric acid stones may crumble. Any blood clots passed in the urine should be crushed and the sides of the urinal and bedpan inspected for clinging stones. Because kidney stones increase the risk of infection, sepsis, and obstruction of the urinary tract, the patient is instructed to report decreased urine volume, bloody or cloudy urine, fever, and pain. Patients with calculi require frequent nursing observation to detect the spontaneous passage of a stone. The patient is instructed to immediately report any sudden increases in pain intensity because of the possibility of a stone fragment obstructing a ureter. Vital signs, including temperature, are monitored closely to detect early signs of infection. UTIs may be associated with kidney stones due to an obstruction from the stone or from the stone itself. All infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. Because the risk of recurring kidney stones is high, the nurse provides education about the causes of kidney stones and recommendations to prevent their recurrence (see Chart 55-12). The patient is encouraged to follow a regimen to avoid further stone formation, including maintaining a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2000 mL (preferably 3000 to 4000 mL) of urine every 24 hours (Cunningham et al., 2016). Urine cultures may be performed every 1 to 2 months in the first year and periodically thereafter. Recurrent UTI is treated vigorously. Because prolonged immobilization slows renal drainage and alters calcium metabolism, increased mobility is encouraged whenever possible. In addition, excessive ingestion of vitamins (especially vitamin D) and minerals is discouraged. If lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical procedures for stone removal have been performed, the nurse instructs the patient about the signs and symptoms of complications (e.g., urinary retention, infection) that need to be reported to the primary provider. The importance of follow-up to assess kidney function and to ensure the eradication or removal of all kidney stones is emphasized to the patient and family. If ESWL has been performed, the nurse must provide instructions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks to several months after the procedure. The patient and family are instructed about signs and symptoms of complications. It is also important to inform the patient to expect hematuria (it is anticipated in all patients), but it should disappear within 4 to 5 days. If the patient has a stent in the ureter, hematuria may be expected until the stent is removed. The patient is instructed to check their temperature daily and notify the primary provider if the temperature is greater than 38°C (about 101°F) or the pain is unrelieved by the prescribed medication. The patient is also informed that a bruise may be observed on the treated side of the back. Continuing and Transitional Care. Close monitoring of the patient in follow-up care is essential to ensure that treatment has been effective and that no complications develop. The nurse has the opportunity to assess the patient's understanding of ESWL and possible complications. In addition, the nurse has the opportunity to assess the patient's understanding of factors that increase the risk of recurrence of renal calculi and strategies to reduce those risks. The nurse must assess the patient's ability to monitor urinary pH and interpret the results during follow-up visits. Because of the high risk of recurrence, the patient with kidney stones needs to understand the signs and symptoms of stone formation, obstruction, and infection and the importance of reporting these signs promptly. If medications are prescribed for the prevention of stone formation, the nurse explains their actions, importance, and side effects to the patient. p. 1636 p. 1637 Evaluation Expected patient outcomes may include: Reports relief of pain States increased knowledge of health-seeking behaviors to prevent recurrence Consumes increased fluid intake (at least eight 8-oz glasses of fluid per day) Participates in appropriate activity Consumes diet prescribed to reduce dietary factors predisposing to stone formation Recognizes symptoms (fever, chills, flank pain, hematuria) to be reported to primary provider Monitors urinary pH as directed Takes prescribed medication as directed to reduce stone formation Experiences no complications Reports no signs or symptoms of infection or urosepsis Voids 200 to 400 mL per voiding of clear urine without evidence of bleeding Experiences absence of urgency, frequency, and hesitancy Maintains normal bo (Hinkle 1632-1637) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Genitourinary trauma

Various types of injuries to the flank, back, or upper abdomen may result in trauma to the ureters, bladder, or urethra. Abdominal trauma is responsible for approximately 90% of all genitourinary trauma (Hallis, Amasyali, Yucak, et al., 2015). Kidney trauma is discussed in Chapter 54. Specific Injuries Ureteral Trauma The main causes are motor vehicle crashes, sports injuries, falls, and assaults (Hallis et al., 2015). Injuries range from contusions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery. There are no specific signs or symptoms of ureteral injury; many traumatic injuries are discovered during exploratory surgery. Surgical repair with placement of stents (to divert urine away from an anastomosis) is usually necessary. If the ureteral trauma is not detected and urine leakage continues, fistulas can develop. Bladder Trauma Injury to the bladder may occur with pelvic fractures, multiple trauma, or from a blow to the lower abdomen when the bladder is full. Blunt trauma may result in contusion evident as an ecchymosis—a large bruise resulting from escape of blood into the tissues and involving a segment of the bladder wall—or in rupture of the bladder extraperitoneally, intraperitoneally, or both. Complications from these injuries include hemorrhage, shock, sepsis, and extravasation of blood into the tissues, which must be treated promptly. Urethral Trauma Urethral injuries usually occur with blunt trauma to the lower abdomen or pelvic region. Many patients also have associated pelvic fractures. The classic triad of symptoms comprises blood at the urinary meatus, inability to void, and a distended bladder. Medical Management The goals of management in patients with genitourinary trauma are to control hemorrhage, pain, and infection and to maintain urinary drainage. Genitourinary trauma is frequently associated with kidney trauma (see Chapter 54). Hematocrit and hemoglobin levels are monitored closely; decreasing values can indicate hemorrhage within the genitourinary system. The patient is also monitored for oliguria, signs of hemorrhagic shock, and signs and symptoms of acute peritonitis. Surgical Management In urethral trauma, a patient whose condition is unstable and who needs monitoring of urine output may need a suprapubic catheter inserted. The patient is catheterized after urethrography has been performed to minimize the risk of urethral disruption and extensive, long-term complications, such as stricture, incontinence, and impotence. Surgical repair may be performed using either open or laparoscopic approaches (Hallis et al., 2015). After surgery, an indwelling urinary catheter may remain in place for up to 1 month. Nursing Management The patient with genitourinary trauma should be assessed frequently during the first few days after injury to detect flank and abdominal pain, muscle spasm, and swelling over the flank. During this time, patients are instructed about care of the incision and the importance of an adequate fluid intake. In addition, instructions about changes that should be reported to the primary provider, such as fever, hematuria, flank pain, or any signs and symptoms of decreasing kidney function, are provided (Hallis et al., 2015). The patient with a ruptured bladder may have gross bleeding for several days after repair. Guidelines for increasing activity gradually, lifting, and driving are also provided. Follow-up nursing care includes monitoring the blood pressure to detect hypertension and advising the patient to restrict activities for about 1 month after trauma to minimize the incidence of delayed or secondary bleeding. (Hinkle 1637) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

adult voiding dysfunction

Both neurogenic and nonneurogenic disorders can cause adult voiding dysfunction (see Table 55-2). The micturition (voiding or urination) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying (see Chapter 53). If voiding dysfunction goes undetected and untreated, the upper urinary system may be compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. (Hinkle 1622) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Cutaneous urinary diversions

Ileal Conduit The ileal conduit (ileal loop) is the oldest and most common of the urinary diversion procedures in use because of the low number of complications and surgeons' familiarity with the procedure. In an ileal conduit, the urine is diverted by implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall. This loop of ileum is a simple conduit (passageway) for urine from the ureters to the surface. A loop of the sigmoid colon may also be used (Rubenwolf et al., 2016). An ileostomy bag is used to collect the urine. The resected (cut) ends of the remaining intestine are anastomosed (connected) to provide an intact bowel. Stents, usually made of thin, pliable tubing, are placed in the ureters to prevent occlusion secondary to postsurgical edema. The bilateral ureteral stents allow urine to drain from the kidney to the stoma and provide a method for accurate measurement of urine output. They may be left in place 10 to 21 days postoperatively. Jackson-Pratt drains or other types of drains are inserted to prevent the accumulation of fluid in the space created by removal of the bladder. After surgery, a skin barrier and a transparent, disposable urinary drainage bag are applied around the conduit and connected to drainage. A custom-cut appliance is used until the edema subsides and the stoma shrinks to normal size. The clear bag allows the stoma to be inspected and the patency of the stent and the urine output to be monitored. The ileal bag drains urine (not feces) continuously. The appliance (bag) usually remains in place as long as it is watertight; it is changed when necessary to prevent leakage of urine. Complications Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, and gangrene of the stoma. Delayed complications include ureteral obstruction, contraction or narrowing of the stoma (stenosis), kidney deterioration due to chronic reflux, pyelonephritis, renal calculi, and cancer recurrence (Rubenwolf et al., 2016; Smolar, Salemi, Horst, et al., 2016). Nursing Management In the immediate postoperative period, urine volumes are monitored hourly. Throughout the patient's hospitalization, the nurse monitors closely for complications, reports signs and symptoms of them promptly, and intervenes quickly to prevent their progression. Figure 55-7 • Types of cutaneous diversions include the conventional ileal conduit (A), cutaneous ureterostomy (B), vesicostomy (C), and nephrostomy (D). A urine output below 0.5 mL/kg/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis. A catheter may be inserted through the urinary conduit to monitor the patient for possible stasis or residual urine from a constricted stoma. Urine may drain through the bilateral ureteral stents as well as around the stents. If the ureteral stents are not draining, the nurse may be instructed to carefully irrigate with 5 to 10 mL sterile normal saline solution, being careful not to exert tension that could dislodge the stent. Hematuria may be noted in the first 48 hours after surgery but usually resolves spontaneously. Providing Stoma and Skin Care Because the patient requires specialized care, a consultation is initiated with a WOC nurse. The stoma is inspected frequently for color and viability. A healthy stoma is pink or red. A change from this normal color to purple, brown, or black suggests that the vascular supply may be compromised. If cyanosis and a compromised blood supply persist, surgical intervention may be necessary. The stoma is not sensitive to touch, but the skin around the stoma becomes sensitive if urine or the appliance causes irritation. The skin is inspected for (1) signs of irritation and bleeding of the stoma mucosa, (2) encrustation and skin irritation around the stoma (from alkaline urine coming in contact with exposed skin), and (3) wound infections (Dukes, Lowther, Martin, et al., 2013). Testing Urine and Caring for the Ostomy Moisture in bed linens or clothing or the odor of urine around the patient should alert the nurse to the possibility of leakage from the appliance, potential infection, or a problem in hygienic management. Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine pH is kept below 6.5 by administration of ascorbic acid by mouth. Urine pH is determined by testing the urine draining from the stoma, not from the collecting appliance. A properly fitted appliance is essential to prevent exposure of the skin around the stoma to urine. If the urine is foul smelling, the stoma is catheterized, if prescribed, to obtain a urine specimen for culture and sensitivity testing. p. 1640 p. 1641 Figure 55-8 • Types of continent urinary diversions include the Indiana pouch (A) and ureterosigmoidostomy (B). Encouraging Fluids and Relieving Anxiety Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes anxiety in many patients. To help relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after an ileal conduit procedure. The nurse encourages adequate fluid intake to flush the ileal conduit and decrease the accumulation of mucus. Selecting the Ostomy Appliance Various urine collection appliances are available, and the nurse is instrumental (often with consultation with a WOC nurse) in selecting an appropriate one. The urinary appliance may consist of one or two pieces and may be disposable (usually used once and discarded) or reusable. The choice of appliance is determined by the location of the stoma and by the patient's normal activity, manual dexterity, visual function, body build, economic resources, and preference. Promoting Home, Community-Based, and Transitional Care Educating Patients About Self-Care Patient education begins in the hospital but continues in the home setting because patients are usually discharged within days of surgery. The nurse instructs the patient how to assess and manage the urinary diversion as well as how to deal with changes in body image. A WOC nurse is invaluable in consulting with the nurse on various aspects of care and patient education. Changing the Appliance The patient and family are educated about how to apply and change the appliance so that they are comfortable carrying out the procedure and can do so proficiently. Ideally, the appliance system is changed before the system leaks and at a time that is convenient for the patient. Many patients find that early morning is most convenient because the urine output is reduced. A variety of appliances are available; an average collecting appliance lasts 3 to 7 days before leakage occurs. Regardless of the type of appliance used, a skin barrier is essential to protect the skin from irritation and excoriation. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. The degree to which the stoma protrudes is not the same in all patients; thus, there are various accessories and custom-made appliances to solve individual problems. Patient guidelines for applying reusable and disposable systems are presented in Chart 55-14. Controlling Odor The patient is instructed to avoid foods that give the urine a strong odor (e.g., asparagus, cheese, eggs). Most appliances contain odor barriers, but, if needed, a few drops of liquid deodorizer or diluted white vinegar may be introduced through the drain spout into the bottom of the pouch with a syringe or eyedropper to reduce odors. Ascorbic acid by mouth helps acidify the urine and suppress urine odor. Patients should be cautioned not to put aspirin tablets in the pouch to control odor, because they may ulcerate the stoma. In addition, the patient is reminded that odor will develop if the pouch is worn longer than recommended and not cared for properly. Managing the Ostomy Appliance The patient is instructed to empty the pouch by means of a drain valve when it is one third full because the weight of more urine will cause the pouch to separate from the skin. Some patients prefer wearing a leg bag attached with an adapter to the drainage apparatus. To promote uninterrupted sleep, a collecting bottle and tubing (one unit) are snapped onto an adapter that connects to the ileal appliance. A small amount of urine is left in the bag when the adapter is attached to prevent the bag from collapsing against itself. The tubing may be threaded down the pajama or pants leg to prevent kinking. The collecting bottle and tubing are rinsed daily with cool water and once a week with a 3:1 solution of water and white vinegar. Cleaning and Deodorizing the Appliance Usually, the reusable appliance is rinsed in warm water and soaked in a 3:1 solution of water and white vinegar or a commercial deodorizing solution for 30 minutes. It is rinsed with tepid water and air-dried away from direct sunlight. (Hot water and exposure to direct sunlight dry the pouch and increase the incidence of cracking.) After drying, the appliance may be powdered with cornstarch and stored. Two appliances are necessary—one to be worn while the other is air-drying. p. 1641 p. 1642 Chart 55-14 PATIENT EDUCATION Using Urinary Diversion Collection Appliances Applying a Reusable Pouch System The nurse instructs the patient to: Gather all necessary supplies. Prepare new appliance according to the manufacturer's directions: Apply double-faced adhesive disc that has been properly sized to fit the reusable pouch faceplate. Remove paper backing and set pouch aside, or apply thin layer of contact cement to one side of the reusable pouch faceplate. Set pouch aside. Remove soiled pouch gently. Lay aside to clean later. Clean peristomal skin (skin around stoma) with small amount of soap and water. Rinse thoroughly and dry. If a film of soap remains on the skin and the site does not dry, the appliance will not adhere adequately. Use a wick (rolled gauze pad or tampon) over the stoma to absorb urine and keep the skin dry throughout the appliance change. Inspect peristomal skin for irritation. Note that a skin protector wipe or barrier ring may be applied before centering the faceplate opening directly over the stoma. Position appliance over stoma, and press gently into place. If desired, use a pouch cover or apply cornstarch under the pouch to prevent perspiration and skin irritation. Clean soiled pouch, and prepare for reuse. Applying a Disposable Pouch System The nurse instructs the patient to: Gather all necessary supplies. Measure stoma, and prepare an opening in the skin barrier about 1/8-inch larger than the stoma and the same shape as the stoma. Remove paper backing from skin barrier, and set aside. Gently remove old appliance, and set aside. Clean peristomal skin with warm water, and dry thoroughly. Inspect peristomal skin (skin around stoma) for irritation. Use a wick (rolled gauze pad or tampon) over the stoma to absorb urine, and keep the skin dry during the appliance change. Center opening of skin barrier over stoma, and apply with firm, gentle pressure to attain a watertight seal. If using a two-piece system, snap pouch onto the flanged wafer that adheres to skin. Close drainage tap or spout at bottom of pouch. Note that a pouch cover can be used or cornstarch applied under pouch to prevent perspiration and skin irritation. Apply hypoallergenic tape around the skin barrier in a picture-frame manner. Dispose of soiled appliance. Adapted from Dukes, S., Lowther, C., Martin, T., et al. (2013). Guidelines for standardising the treatment of stoma granulomas at the mucocutaneous junction. World Council of Enterostomal Therapists Journal, 33(1), 12-15. Continuing and Transitional Care Follow-up care is essential to determine how the patient has adapted to the altered body image and lifestyle changes. Referral for home care is indicated to determine how well the patient and family are coping with the urinary drainage diversion. The nurse assesses the patient's physical status and emotional response. In addition, the nurse assesses the ability of the patient and family to manage the urinary diversion and appliance, reinforces previous education, and provides additional information (e.g., community resources, sources of ostomy supplies, insurance coverage for supplies). As the postoperative edema subsides, the nurse assists in determining the appropriate changes needed in the ostomy appliance. The size of the stoma is measured every 3 to 6 weeks for the first few months postoperatively. The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage. The nurse educates the patient and family about resources (see the Resources section at the end of this chapter). Local chapters of the American Cancer Society (ACS) can provide medical equipment and supplies and other resources for the patient who has undergone ostomy surgery for cancer. The home care nurse assesses the patient for potential long-term complications such as ureteral obstruction, stenosis, hernias, or deterioration of kidney function (Rubenwolf et al., 2016). The nurse also reinforces previous education about these complications. Cutaneous Ureterostomy A cutaneous ureterostomy (see Fig. 55-7), in which the ureters are directed through the abdominal wall and attached to an opening in the skin, is used for selected patients with ureteral obstruction (i.e., advanced pelvic cancer) because it requires less extensive surgery than other urinary diversion procedures. It is also an appropriate procedure for patients who have had previous abdominal irradiation. A urinary appliance is fitted immediately after surgery. The management of the patient with a cutaneous ureterostomy is similar to the care of the patient with an ileal conduit, although the stomas are usually flush with the skin or retracted. (Hinkle 1639-1642) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

catheterization

In patients with a urologic disorder or with marginal kidney function, care must be taken to ensure that urinary drainage is adequate and that kidney function is preserved. When urine cannot be eliminated naturally and must be drained artificially, catheters may be inserted directly into the bladder, the ureter, or the renal pelvis. Catheters vary in size, shape, length, material, and configuration (Carter et al., 2014). The type of catheter used depends on its purpose. Catheterization is performed to achieve the following: Relieve urinary tract obstruction Assist with postoperative drainage in urologic and other surgeries Provide a means to monitor accurate urine output in patients who are critically ill Promote urinary drainage in patients with neurogenic bladder dysfunction or urine retention Prevent urinary leakage in patients with stage III to IV pressure ulcers (see Chapter 10) A patient should be catheterized only if necessary, because catheterization commonly leads to UTI. Catheters impede most of the natural defenses of the lower urinary tract by obstructing the periurethral ducts, irritating the bladder mucosa, and providing an artificial route for organisms to enter the bladder (Hagerty et al., 2015). Organisms may be introduced from the urethra into the bladder during catheterization, or they may migrate along the epithelial surface of the urethra or external surface of the catheter. In addition, urinary catheters have been associated with other complications, such as bladder spasms, urethral strictures, and pressure necrosis (Bader et al., 2016). Indwelling Catheters When an indwelling catheter cannot be avoided, a closed drainage system is essential. This drainage system is designed to prevent any disconnections, thereby reducing the risk of contamination. Triple-lumen catheters are commonly used after transurethral prostate surgery (see Chapter 59). This system has a triple-lumen indwelling urethral catheter attached to a closed sterile drainage system. With the triple-lumen catheter, urinary drainage occurs through one channel. The retention balloon of the catheter is inflated with water or air through the second channel, and the bladder is continuously irrigated with sterile irrigating solution through the third channel. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. By keeping the drainage bag lower than the patient's bladder and not allowing urine to flow back into the bladder, this risk is reduced. Suprapubic Catheters Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture (see Fig. 55-3). The catheter or suprapubic drainage tube is then threaded into the bladder and secured with sutures or tape, and the area around the catheter is covered with a sterile dressing. The catheter is connected to a sterile closed drainage system, and the tubing is secured to prevent tension on the catheter. This may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable (because of injuries, strictures, prostatic obstruction), after gynecologic or other abdominal surgery when bladder dysfunction is likely to occur, and occasionally after pelvic fractures. Figure 55-3 • Suprapubic bladder drainage. A trocar cannula is used to puncture the abdominal and bladder walls. The catheter is threaded through the trocar cannula, which is then removed, leaving the catheter in place. The catheter is secured by tape or sutures to prevent unintentional removal. Suprapubic bladder drainage may be maintained continuously for several weeks. When the patient's ability to void is to be tested, the catheter is clamped for 4 hours, during which time the patient attempts to void. After the patient voids, the catheter is unclamped, and the residual urine is measured. If the amount of residual urine is less than 100 mL on two separate occasions (morning and evening), the catheter is usually removed. However, if the patient complains of pain or discomfort, the suprapubic catheter is usually left in place until the patient can void successfully. Suprapubic drainage offers certain advantages. Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. The suprapubic catheter is removed when it is no longer required, and a sterile dressing is placed over the site. The patient requires liberal amounts of fluid to prevent encrustation around the catheter. Other potential problems include the formation of bladder stones, acute and chronic infections, and problems collecting urine. A wound-ostomy-continence (WOC) nurse may be consulted to assist the patient and family in selecting the most suitable urine collection system and to educate them about its use and care. Nursing Management Assessing the Patient and the System For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of kidney function and urinary drainage. Patients at high risk for UTI from catheterization need to be identified and monitored carefully. These include women; older adults; and patients who are debilitated, malnourished, chronically ill, immunosuppressed, or have diabetes (Carter et al., 2014; Hagerty et al., 2015). They are observed for signs and symptoms of UTI: cloudy malodorous urine, hematuria, fever, chills, anorexia, and malaise. Any drainage and excoriation in the area around the urethral orifice is noted. Urine cultures provide the most accurate means of assessing a patient for infection. Gerontologic Considerations The older patient with an indwelling catheter may not exhibit the typical signs and symptoms of infection (Eliopoulos, 2018). Therefore, any subtle change in physical condition or mental status must be considered a possible indication of infection and promptly investigated because sepsis may occur before the infection is diagnosed. Figure 55-4 summarizes the sequence of events leading to infection and leakage of urine that often follow long-term use of an indwelling catheter in an older patient (Miller, 2015). Figure 55-4 • Pathophysiology and manifestations of bladder infection with long-term catheterization in older patients. Preventing Infection Certain principles of care are essential to prevent infection in patients with a closed urinary drainage system (see Chart 55-10). The catheter is an object foreign to the body and produces a reaction in the urethral mucosa with some urethral discharge. Vigorous cleansing of the meatus while the catheter is in place is discouraged because the cleansing action can move the catheter back and forth, increasing the risk of infection. To clean the external catheter surface, gentle washing with soap and water or wipes during the daily bath is used by some (Strouse, 2015). Others report that using 2% chlorhexidine gluconate no-rinse wipes during the daily bath helps decrease CAUTI rates (Carter et al., 2014). The catheter is anchored as securely as possible to prevent it from moving in the urethra (Carter et al., 2014; Mori, 2014). Chart 55-10 Preventing Infection in the Patient With an Indwelling Urinary Catheter Avoid contamination of the drainage spout. A receptacle in which to empty the bag is provided for each patient. Avoid routine catheter changes. The catheter is changed only to correct problems such as leakage, blockage, or encrustations. Avoid unnecessary handling or manipulation of the catheter by the patient or staff. Carry out hand hygiene before and after handling the catheter, tubing, or drainage bag. Ensure a free flow of urine to prevent infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing loops. Evaluate the benefit of placing an indwelling urinary catheter versus the risk the patient developing a catheter-associated urinary tract infection. If the collection bag must be raised above the level of the patient's bladder, clamp the drainage tube. This prevents backflow of contaminated urine into the patient's bladder from the bag. Monitor the patient's voiding when the catheter is removed. The patient must void within 8 hours; if unable to void, the patient may require catheterization with a straight catheter. Never disconnect the tubing to obtain urine samples, to irrigate the catheter, or to ambulate or transport the patient. Never irrigate the catheter routinely. If the patient is prone to obstruction from clots or large amounts of sediment, use a three-way system with continuous irrigation. Never leave the catheter in place longer than is necessary to decrease the risk of CAUTI. Obtain a urine specimen for culture at the first sign of infection. To prevent contamination of the closed system, never disconnect the tubing. The drainage bag must never touch the floor. The bag and collecting tubing are changed if contamination occurs, if urine flow becomes obstructed, or if tubing junctions start to leak at the connections. To reduce the risk of bacterial proliferation, empty the collection bag at least every 8 hours through the drainage spout—more frequently if there is a large volume of urine. Use scrupulous aseptic technique during insertion of the catheter. Use a preassembled, sterile, closed urinary drainage system of the smallest catheter size possible to minimize trauma. Wash the perineal area with soap and water at least twice a day; avoid a to-and-fro motion of the catheter. Dry the area well, but avoid applying powder because it may irritate the perineum. Adapted from Carter, N. M., Reitmeier, L., & Goodloe, L. R. (2014). An evidence-based approach to the prevention of catheter-associated urinary tract infections. Urologic Nursing, 34(5), 238-245. A liberal fluid intake, within the limits of the patient's cardiac and renal reserve, and an increased urine output must be ensured to flush the catheter and to dilute urinary substances that might form encrustations (Carter et al., 2014; Hagerty et al., 2015). Urine cultures are obtained as prescribed or indicated when monitoring the patient for infection; many catheters have an aspiration (puncture) port from which a specimen can be obtained. Bacteriuria is considered inevitable in patients with indwelling catheters; therefore, controversy remains about the usefulness of taking cultures and treating asymptomatic bacteriuria, because overtreatment may lead to resistant strains of bacteria. Continual observation for fever, chills, and other signs and symptoms of systemic infection is necessary. Infections are treated aggressively. Minimizing Trauma Trauma to the urethra can be minimized by: Using an appropriately sized catheter Lubricating the catheter adequately with a water-soluble lubricant during insertion Inserting the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon of the catheter is inflated Manipulation of the catheter is the most common cause of trauma to the bladder mucosa in the catheterized patient. Infection can occur when urine invades the damaged mucosa. The catheter is secured properly to prevent it from moving, causing traction on the urethra, or being unintentionally removed, and care is taken to ensure that the catheter position permits leg movement. In male patients, the drainage tube (not the catheter) is taped laterally to the thigh to prevent pressure on the urethra at the penoscrotal junction, which can eventually lead to formation of a urethrocutaneous fistula. In female patients, the drainage tubing attached to the catheter is taped to the thigh to prevent tension and traction on the bladder. Special care should be taken to ensure that any patient who is confused does not remove the catheter with the retention balloon still inflated, because this could cause bleeding and considerable injury to the urethra. Retraining the Bladder When an indwelling urinary catheter is in place, the detrusor muscle does not actively contract the bladder wall to stimulate emptying because urine is continuously draining from the bladder. As a result, the detrusor may not immediately respond to bladder filling when the catheter is removed, resulting in either urine retention or urinary incontinence. This condition, known as postcatheterization detrusor instability, can be managed with bladder retraining (see Chart 55-11). Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner, and if the bladder has not emptied completely, straight catheterization may be performed (Carter et al., 2014; Mori, 2014). After a few days, as the nerve endings in the bladder wall become resensitized to the bladder filling and emptying, bladder function usually returns to normal. If the patient has had an indwelling catheter in place for an extended period (e.g., greater than 1 month), bladder retraining will take longer; in some cases, function may never return to normal, and long-term intermittent catheterization may become necessary. Assisting With Intermittent Self-Catheterization Intermittent self-catheterization provides periodic drainage of urine from the bladder. By promoting drainage and eliminating excessive residual urine, intermittent catheterization protects the kidneys, reduces the incidence of UTIs, and improves continence. It is the treatment of choice in some patients with spinal cord injury and other neurologic disorders, such as multiple sclerosis, when the ability to empty the bladder is impaired. Self-catheterization promotes independence, results in few complications, and enhances self-esteem and quality of life. Chart 55-11 Bladder Retraining After Indwelling Catheterization Instruct the patient to drink a measured amount of fluid from 8 am to 10 pm to avoid bladder overdistention. Offer no fluids (except sips) after 10 pm. At specific times, ask the patient to void by applying pressure over the bladder, tapping the abdomen, or running water to trigger the bladder. Immediately after the voiding attempt, perform a bladder scan to determine the amount of residual urine. Measure the volumes of urine voided. Palpate the bladder at repeated intervals to assess for distention. Instruct the patient who has no voiding sensation to be alert to any signs that indicate a full bladder, such as perspiration, cold hands or feet, or feelings of anxiety. Perform straight catheterization, as prescribed, usually for residual urine of >300 mL. Lengthen the intervals between catheterizations as the volume of residual urine decreases. Catheterization is usually discontinued when the volume of residual urine is <100 mL. Adapted from Carter, N. M., Reitmeier, L., & Goodloe, L. R. (2014). An evidence-based approach to the prevention of catheter-associated urinary tract infections. Urologic Nursing, 34(5), 238-245. When educating the patient about how to perform self-catheterization, the nurse must use aseptic technique to minimize the risk of cross-contamination. However, the patient may use a "clean" (nonsterile) technique at home, where the risk of cross-contamination is reduced. Either antibacterial liquid soap or povidone-iodine (Betadine) solution is recommended for cleaning urinary catheters at home. The catheter is thoroughly rinsed with warm tap water after soaking in the cleaning solution. It must dry before reuse. It should be kept in its own container, such as a plastic food storage bag. In educating the patient, the nurse emphasizes the importance of frequent catheterization and emptying the bladder at the prescribed time. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. If the patient is awakened at night with an urge to void, catheterization may be performed after an attempt is made to void normally. The female patient assumes a Fowler position and uses a mirror to help locate the urinary meatus. She lubricates the catheter and inserts it 7.5 cm (3 inches) into the urethra, in a downward and backward direction. The male patient assumes a Fowler or sitting position, lubricates the catheter, and retracts the foreskin of the penis with one hand while grasping the penis and holding it at a right angle to the body. (This maneuver straightens the urethra and makes it easier to insert the catheter.) He inserts the catheter 15 to 25 cm (6 to 10 inches) until urine begins to flow. After removal, the catheter is cleaned, rinsed, dried, and placed in a plastic bag or case. Patients who follow an intermittent catheterization routine should consult a primary provider at regular intervals to assess urinary function and to detect complications. If the patient cannot perform intermittent self-catheterization, a family member or caregiver may be taught to carry out the procedure at regular intervals during the day. An alternative to self-catheterization is creation of the Mitrofanoff umbilical appendicovesicostomy, which provides easy access to the bladder but requires an extensive surgical procedure (Wille, Zagaja, Shalhav, et al., 2011). In this procedure, the bladder neck is closed and the appendix is used to create access to the bladder from the skin surface through a submucosal tunnel created with the appendix. One end of the appendix is brought to the skin surface and used as a stoma, and the other end is tunneled into the bladder. The appendix serves as an artificial urinary sphincter when an alternative is necessary to empty the bladder. A surgically prepared continent urine reservoir with a sphincter mechanism is required in cases of bladder cancer and severe interstitial cystitis. Various types of urinary diversions may be used when a radical cystectomy (surgical removal of the bladder) is necessary (see discussion later in ch (Hinkle 1628-1632) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

urinary incontinence

More than 25 million adults in the United States are estimated to have urinary incontinence (involuntary or uncontrolled loss of urine from the bladder), with most of them experiencing overactive bladder syndrome, making this disorder more prevalent than diabetes or ulcer disease (Miller, 2015). Despite widespread media coverage, urinary incontinence remains underdiagnosed and underreported. Patients may be too embarrassed to seek help, causing them to ignore or conceal symptoms. Many patients use absorbent pads or other devices without having their condition properly diagnosed and treated (Day, Leahy-Warren, Loughran, et al., 2014). Health care providers must be alert to subtle cues of urinary incontinence and stay informed about current management strategies. The costs of care for patients with urinary incontinence include the expenses of absorbent products, medications, and surgical or nonsurgical treatment modalities, as well as psychosocial costs (i.e., embarrassment, loss of self-esteem, and social isolation) (Day et al., 2014; McCooty & Latthe, 2014). Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it can occur in young nulliparous women, especially during vigorous high-impact activity. Age, gender, and number of vaginal deliveries are established risk factors that explain, in part, the increased incidence in women (see Chart 55-6). Men can have urinary incontinence, especially those with certain comorbid conditions. One group of researchers, for example, reported that 40% of men with Parkinson disease reported urinary incontinence (Robinson, Bradway, Bunting-Perry, et al., 2013). Urinary incontinence is a symptom of many possible disorders. Types of Urinary Incontinence There are many types of urinary incontinence, including the following: Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position (Miller, 2015; Weber & Kelley, 2014). It predominantly affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability. (Hinkle 1623-1624) Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed (Miller, 2015; Weber & Kelley, 2014). The patient is aware of the need to void but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction. Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment (e.g., Alzheimer dementia), make it difficult for the patient to identify the need to void or physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding (Miller, 2015). Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to decrease blood pressure. In some people with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intra-abdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves. Mixed urinary incontinence, which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing (Miller, 2015). Only with appropriate recognition of the problem, assessment, and referral for diagnostic evaluation and treatment can the outcome of incontinence be determined. All people with incontinence should be considered for evaluation and treatment. Gerontologic Considerations Although urinary incontinence is not a normal consequence of aging, age-related changes in the urinary tract do predispose the older person to incontinence. However, if nurses and other health care providers accept incontinence as an inevitable part of illness or aging or consider it irreversible and untreatable, it cannot be treated successfully. Collaborative, interdisciplinary efforts are essential in assessing and effectively treating urinary incontinence. Urinary incontinence can decrease an older person's ability to maintain an independent lifestyle, which increases dependence on caregivers and may lead to institutionalization. Between 25% and 45% of older women have urinary incontinence (Day et al., 2014). Many older adults experience transient episodes of incontinence that tend to be abrupt in onset. When this occurs, the nurse should question the patient, as well as the family if possible, about the onset of symptoms and any signs or symptoms of a change in other organ systems. Acute UTI, infection elsewhere in the body, constipation, decreased fluid intake, and a change in a chronic disease pattern, such as elevated blood glucose levels in patients with diabetes or decreased estrogen levels in menopausal women, can provoke the onset of urinary incontinence. If the cause is identified and modified or eliminated early at the onset of incontinence, the incontinence itself may be eliminated. Although the bladder of the older person is more vulnerable to altered detrusor activity, age alone is not a risk factor for urinary incontinence (Miller, 2015). Decreased bladder muscle tone is a normal age-related change found in older adults. This leads to decreased bladder capacity, increased residual urine (urine remaining in the bladder after voiding), and an increase in urgency. Many medications affect urinary continence in addition to causing other unwanted or unexpected effects (Miller, 2015). All medications need to be assessed for potential interactions. Assessment and Diagnostic Findings Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of medication use. The patient's voiding history, a diary of fluid intake and output, and bedside tests (e.g., residual urine, stress maneuvers) may be used to help determine the type of urinary incontinence involved. Extensive urodynamic tests may be performed (see Chapter 53). Urinalysis and urine culture are performed to identify infection. Urinary incontinence may be transient or reversible if the underlying cause is successfully treated and the voiding pattern reverts to normal. Chart 55-7 provides causes of transient incontinence. Medical Management Management depends on the type of urinary incontinence and its causes. Management of urinary incontinence may be behavioral, pharmacologic, or surgical. Behavioral Therapy Behavioral therapies are the first choice to decrease or eliminate urinary incontinence (see Chart 55-8). In using these techniques, health care professionals help patients avoid potential adverse effects of pharmacologic or surgical interventions. Pelvic floor muscle exercises (sometimes referred to as Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence (Miller, 2015; Weber & Kelley, 2014). Other behavioral treatments include the use of a voiding diary, biofeedback, verbal instruction (prompted voiding), and physical therapy (Day et al., 2014; McCooty & Latthe, 2014). (Hinkle 1624) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file. Pharmacologic Therapy Pharmacologic therapy works best when used as an adjunct to behavioral interventions. Anticholinergic agents inhibit bladder contraction and are considered first-line medications for urge incontinence. A tricyclic antidepressant medication (e.g., amitriptyline [Elavil]) can also decrease bladder contractions as well as increase bladder neck resistance (Comerford, 2015). Pseudoephedrine sulfate (Sudafed), which acts on alpha-adrenergic receptors, causing urinary retention, may be used to treat stress incontinence; it needs to be used with caution in men with prostatic hyperplasia and patients with hypertension. Surgical Management Surgical correction may be indicated in patients who have not achieved continence using behavioral and pharmacologic therapy. Surgical options vary according to the underlying anatomy and the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra. Women with stress incontinence may undergo an anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra. Procedures to compress the urethra and increase resistance to urine flow include sling procedures and placement of periurethral bulking agents such as artificial collagen. Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen are placed within the walls of the urethra to enhance the closing pressure of the urethra (Matsuoka, Locali, Pacetta, et al., 2016). This procedure takes only 10 to 20 minutes and may be performed under local anesthesia or moderate sedation. A cystoscope is inserted into the urethra. An instrument is inserted through the cystoscope to deliver a small amount of collagen into the urethral wall at locations selected by the urologist. The patient is usually discharged home after voiding. There are no restrictions following the procedure, although occasionally more than one collagen bulking session may be necessary if the initial procedure did not halt stress incontinence. Collagen placement anywhere in the body is considered semipermanent because its durability averages between 12 and 24 months, until the body absorbs the material. Periurethral bulking with collagen is a relatively safe alternative to surgery (Matsuoka et al., 2016). It is also an option for people who are seeking help with stress incontinence who prefer to avoid surgery and who do not have access to behavioral therapies. An artificial urinary sphincter can be used to close the urethra and promote continence. Two types of artificial sphincters are a periurethral cuff and a cuff inflation pump. Men with overflow and stress incontinence may undergo a transurethral resection to relieve symptoms of prostatic enlargement. An artificial sphincter can be used after prostatic surgery for sphincter incompetence (see Fig. 55-2). After surgery, periurethral bulking agents can be injected into the periurethral area to increase compression of the urethra (Matsuoka et al., 2016). Figure 55-2 • Male artificial urinary sphincter. An inflatable cuff is inserted surgically around the urethra or neck of the bladder. To empty the bladder, the cuff is deflated by squeezing the control pump located in the scrotum. Nursing Management Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. The nursing interventions are determined in part by the type of treatment that is undertaken. For behavioral therapy to be effective, the nurse must provide support and encouragement, because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence. Patient education is important and should be provided verbally and in writing (see Chart 55-9). The patient should be educated to develop and use a log or diary to record timing of pelvic floor muscle exercises, frequency of voiding, any changes in bladder function, and any episodes of incontinence (Miller, 2015). Chart 55-9 PATIENT EDUCATION Strategies for Promoting Urinary Continence The nurse instructs the patient to: Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet). Avoid taking diuretic agents after 4 pm. Increase awareness of the amount and timing of all fluid intake. Perform all pelvic floor muscle exercises as prescribed, every day. Stop smoking (smokers usually cough frequently, which increases incontinence). Take steps to avoid constipation: Drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take stool softeners if recommended. Void regularly, 5-8 times a day (about every 2-3 hours): First thing in the morning Before each meal Before retiring to bed Once during the night if necessary If pharmacologic treatment is used, the patient and family are educated about its purpose. Patients with mixed incontinence must be informed that anticholinergic and antispasmodic agents can help decrease urinary urgency and frequency and urge incontinence but do not decrease the urinary incontinence related to stress incontinence. If surgical correction is undertaken, the procedure and its desired outcomes are described to the patient and family. Follow-up contact with the patient enables the nurse to answer the patient's questions and to provide reinforcement and encouragement. (Hinkle 1626-1627) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process lower uti

NURSING PROCESS The Patient With a Lower Urinary Tract Infection Lower Urinary Tract Infection case study Click to Show Nursing care of the patient with a lower UTI focuses on treating the underlying infection and preventing its recurrence. Assessment A history of pertinent signs and symptoms is obtained from the patient with a suspected UTI. The presence of pain, frequency, urgency, hesitancy, and changes in urine are assessed, documented, and reported. The patient's usual pattern of voiding is assessed to detect factors that may predispose him or her to UTI. Infrequent emptying of the bladder, the association of symptoms of UTI with sexual intercourse, contraceptive practices, and personal hygiene are assessed. The patient's knowledge about prescribed antimicrobial medications and preventive health care measures is also assessed. In addition, the urine is assessed for volume, color, concentration, cloudiness, and odor—all of which are altered by bacteria in the urinary tract. Patients need to be asked specifically about the use of complementary and alternative therapies. Researchers in one study reported that women with interstitial cystitis (inflammation of the bladder wall) used both complementary and conventional therapies. The most common complementary therapies reported included diet, biofeedback, dietary supplements, meditation, yoga, and massage (Anderson & Zinkgraf, 2013). Diagnosis NURSING DIAGNOSES Based on the assessment data, nursing diagnoses may include the following: Acute pain related to infection within the urinary tract Deficient knowledge about factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Sepsis (urosepsis) Acute kidney injury and/or chronic kidney disease may occur as the long-term result of either an extensive infective or inflammatory process Planning and Goals Major goals for the patient may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications. Nursing Interventions RELIEVING PAIN The pain associated with a UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Analgesic agents and the application of heat to the perineum help relieve pain and spasm. The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to promote renal blood flow and to flush the bacteria from the urinary tract. Urinary tract irritants (e.g., coffee, tea, citrus, spices, colas, alcohol) should be avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely, because doing so can lower urine bacterial counts, reduce urinary stasis, and prevent reinfection (Bass-Ware, et al., 2014; Hopkins et al., 2014). MONITORING AND MANAGING POTENTIAL COMPLICATIONS Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as kidney disease, sepsis (urosepsis), strictures, and obstructions. The goal of treatment is to prevent infection from progressing and causing permanent kidney damage and injury. Thus, the patient must be educated to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTIs. The patient is instructed to notify the primary provider if fatigue, nausea, vomiting, fever, or pruritus occurs. Periodic monitoring of renal function and evaluation for strictures, obstructions, or stones may be indicated for patients with recurrent UTIs. Patients with UTIs are at increased risk for gram-negative sepsis. For each day a urinary catheter is in place, the risk of developing catheter-associated urinary tract infection (CAUTI) increases. The risk of sepsis in patients with a urinary catheter is about 15% (Booker, 2015). CAUTIs should be avoided as they result in unpleasant symptoms, additional pharmacologic therapy, serious complications, and delayed discharge (Booker, 2015; Carter, Reitmeier, & Goodloe, 2014). If an indwelling catheter is necessary, the following specific nursing interventions are initiated to prevent infection and urosepsis: Using strict aseptic technique during insertion of the smallest catheter possible Securing the catheter to prevent movement Frequently inspecting urine color, odor, and consistency Performing meticulous daily perineal care with soap and water Maintaining a closed system Following the manufacturer's instructions when using the catheter port to obtain urine specimens Careful assessment of vital signs and level of consciousness may alert the nurse to kidney involvement or impending sepsis. Positive blood cultures and elevated WBC counts must be reported immediately. At the same time, appropriate antibiotic therapy and increased fluid intake are prescribed (IV antibiotic therapy and fluids may be required). Aggressive early treatment is the key to reducing the mortality rate associated with CAUTI especially in older patients, those with anemia, and those with elevated blood sugar levels (Hagerty et al., 2015). See Chart 55-4 for more information on risk factors for CAUTIs. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. In helping patients learn about and prevent or manage a recurrent UTI, the nurse implements education that meets the patient's needs. Health-related behaviors that help prevent recurrent UTIs include practicing careful personal hygiene, increasing fluid intake to promote voiding and dilution of urine, urinating regularly and more frequently, and adhering to the therapeutic regimen. For a detailed discussion of patient education, see Chart 55-5. Evaluation Expected patient outcomes may include: Experiences relief of pain Reports absence of pain, urgency, frequency, nocturia, or hesitancy on voiding Takes analgesic, antispasmodic, and antibiotic agents as prescribed Explains UTIs and their treatment Demonstrates knowledge of preventive measures and prescribed treatments Drinks 8 to 10 glasses of fluids daily Voids every 2 to 3 hours Produces urine that is clear and odorless Experiences no complications Reports no symptoms of infection (fever, frequency) Has normal kidney function, negative urine and blood cultures Exhibits normal vital signs and temperature; no signs or symptoms of sepsis (urosepsis) Maintains adequate urine output more than 0.5 mL/kg/hr (Hinkle 1619-1621) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Neurogenic bladder

Neurogenic bladder is a dysfunction that results from a disorder or dysfunction of the nervous system and leads to urinary incontinence. It may be caused by spinal cord injury, spinal tumor, herniated vertebral disc, multiple sclerosis, congenital disorders (spina bifida or myelomeningocele), infection, or complications of diabetes (Bader, Littlejohns, & Olson, 2016) (see Chapters 51, 68, and 69). Pathophysiology The two types of neurogenic bladder are spastic (or reflex) bladder and flaccid bladder. Spastic bladder is the more common type and is caused by any spinal cord lesion above the voiding reflex arc (upper motor neuron lesion) (Bader et al., 2016). The result is a loss of conscious sensation and cerebral motor control. A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity. Flaccid bladder is caused by a lower motor neuron lesion, commonly resulting from trauma. This form of neurogenic bladder is also increasingly being recognized in patients with diabetes. The bladder continues to fill and becomes greatly distended, and overflow incontinence occurs. The bladder muscle does not contract forcefully at any time. Because sensory loss may accompany a flaccid bladder, the patient feels no discomfort. Assessment and Diagnostic Findings Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residual urine volume; urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies are also performed. Complications The most common complication of neurogenic bladder is infection resulting from urinary stasis and catheterization. Other complications include renal calculi, impaired skin integrity, and urinary incontinence or retention (Bader et al., 2016). Medical Management The problems resulting from neurogenic bladder disorders vary considerably from patient to patient and are a major challenge to the health care team. Several long-term objectives appropriate for all types of neurogenic bladders include preventing overdistention of the bladder, emptying the bladder regularly and completely, maintaining urine sterility with no stone formation, and maintaining adequate bladder capacity with no reflux. Specific interventions include continuous, intermittent, or self-catheterization (discussed later in this chapter); the use of an external condom-type catheter; a diet low in calcium (to prevent calculi); and encouragement of mobility and ambulation. A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce stasis, decrease the concentration of calcium in the urine, and minimize the precipitation of urinary crystals and subsequent stone formation. A bladder retraining program may be effective in treating a spastic bladder or urine retention. The use of a timed, or habit, voiding schedule may be established. To further enhance emptying of a flaccid bladder, the patient may be taught to "double void." After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Pharmacologic Therapy Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase the contraction of the detrusor muscle. Surgical Management Surgery may be carried out to correct bladder neck contractures or vesicoureteral reflu (Hinkle 1628) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

upper urinary tract infection

Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the bloodstream. Pathogenic bacteria from a bladder infection can ascend into the kidney, resulting in pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection (see Fig. 55-1), because static urine provides a good medium for bacterial growth. Bladder or prostate tumors, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses. (Hinkle 1621-1622) Pyelonephritis may be acute or chronic. Acute pyelonephritis usually leads to enlargement of the kidneys with interstitial infiltrations of inflammatory cells (Grossman & Porth, 2014). Abscesses may be noted on or within the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. When pyelonephritis becomes chronic, the kidneys become scarred, contracted, and nonfunctioning. Chronic pyelonephritis is a cause of chronic kidney disease that can result in the need for renal replacement therapies such as transplantation or dialysis. Acute Pyelonephritis Clinical Manifestations The patient with acute pyelonephritis has chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle (see Fig. 53-6 in Chapter 53). In addition, symptoms of lower urinary tract involvement, such as urgency and frequency, are common. Assessment and Diagnostic Findings An ultrasound study or a CT scan may be performed to locate an obstruction in the urinary tract. Relief of obstruction is essential to prevent complications and eventual kidney damage. An IV pyelogram may be indicated with pyelonephritis if functional and structural renal abnormalities are suspected (Fischbach & Dunning, 2015). Radionuclide imaging with gallium citrate and indium-111 (111In)-labeled WBCs may be useful to identify sites of infection that may not be visualized on CT scan or ultrasound. Urine culture and sensitivity tests are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed (Fischbach & Dunning, 2015). Medical Management Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting acute symptoms of sepsis, dehydration, nausea, or vomiting. In addition, they must be responsible and reliable to ensure that all medications will be taken as prescribed. For outpatients, a 2-week course of antibiotic agents is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections. Commonly prescribed agents include many of the same medications prescribed for the treatment of UTIs (see Table 55-1). Following acute pyelonephritis treatment, the patient may develop a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if a relapse occurs. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. Hydration with oral or parenteral fluids is essential in all patients with UTIs when there is adequate kidney function. Hydration helps facilitate "flushing" of the urinary tract and reduces pain and discomfort. Chronic Pyelonephritis Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis. Clinical Manifestations The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, resulting in chronic kidney disease (see Chapter 54). Assessment and Diagnostic Findings The extent of the disease is assessed by an IV urogram and measurements of creatinine clearance, blood urea nitrogen, and creatinine levels (Fischbach & Dunning, 2015). Complications Complications of chronic pyelonephritis include end-stage kidney disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of kidney stones (from chronic infection with urea-splitting organisms). Medical Management Bacteria, if detected in the urine, are eradicated if possible. Long-term use of prophylactic antimicrobial therapy may help limit recurrence of infections and kidney scarring. Impaired kidney function alters the excretion of antimicrobial agents and necessitates careful monitoring of kidney function, especially if the medications are potentially toxic to the kidneys. Nursing Management The patient may require hospitalization or may be treated as an outpatient. When the patient requires hospitalization, fluid intake and output are carefully measured and recorded. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. The nurse assesses the patient's temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed. Patient education focuses on prevention of further infection by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking antimicrobial medications exactly as prescribed is stressed, as is the need for keeping follow-up appointments. (Hinkle 1622) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

lower urinary tract infection

Several mechanisms maintain the sterility of the bladder: the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and antiadherent effects mediated by the mucosal cells of the bladder. Abnormalities or dysfunctions of these mechanisms are contributing risk factors for lower UTIs (see Chart 55-2). Pathophysiology For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation. Many UTIs result from fecal organisms ascending from the perineum to the urethra and the bladder and then adhering to the mucosal surfaces. (Hinkle 1616) Bacterial Invasion of the Urinary Tract By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder can clear large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and tryptophan metabolites). The normal bacterial flora of the vagina and urethral area also interfere with adherence of Escherichia coli. Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria. Reflux An obstruction to free-flowing urine is a condition known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder (see Fig. 55-1). With coughing, sneezing, or straining, the bladder pressure increases, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection in postmenopausal women. Reflux is most often noted in young children, and treatment is based on its severity. Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into one or both ureters (see Fig. 55-1). Normally, the ureterovesical junction prevents urine from traveling back into the ureter. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and eventually destroy them. Figure 55-1 • Mechanisms of urethrovesical and ureterovesical reflux may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A. When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine. Uropathogenic Bacteria Bacteriuria is the term used to describe the presence of bacteria in the urine. Because urine samples (especially in women) can be easily contaminated by the bacteria normally present in the urethral area, a clean-catch midstream urine specimen is the measure used to establish bacteriuria. In men, contamination of the collected urine sample occurs less frequently. Bacteriuria is defined as 100,000 colony-forming units (CFU)/mL urine (Fischbach & Dunning, 2015; Grossman & Porth, 2014). Community-acquired UTIs are among the most common bacterial infections in women (Hopkins, et al., 2014).The organisms most frequently responsible for UTIs are those normally found in the lower gastrointestinal (GI) tract, usually Escherichia coli (Grossman & Porth, 2014). Routes of Infection Bacteria enter the urinary tract in three ways: by the transurethral route (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension). The most common route of infection is transurethral, in which bacteria (often from fecal contamination) colonize the periurethral area and subsequently enter the bladder by means of the urethra (Grossman & Porth, 2014). In women, the short urethra offers little resistance to the movement of uropathogenic bacteria. Sexual intercourse forces the bacteria from the urethra into the bladder. This accounts for the increased incidence of UTIs in sexually active women. Bacteria may also enter the urinary tract by means of the blood from a distant site of infection or through direct extension by way of a fistula from the intestinal tract. Clinical Manifestations Signs and symptoms of UTI depend on whether the infection involves the lower (bladder) or upper (kidney) urinary tract and whether the infection is acute or chronic. Signs and symptoms of an uncomplicated lower UTI include burning on urination, urinary frequency (voiding more than every 3 hours), urgency, nocturia (awakening at night to urinate), incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present. In older adults, these symptoms are less common (see Gerontologic Considerations section). In patients with complicated UTIs, manifestations can range from asymptomatic bacteriuria to gram-negative sepsis with shock. Complicated UTIs often are caused by a broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients with catheter-associated UTIs are asymptomatic; however, any patient with a catheter who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis (the spread of infection from the urinary tract to the bloodstream that results in a systemic infection). Gerontologic Considerations The incidence of bacteriuria in older adults differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common infection of older adults and increases in prevalence with age. UTIs occur more frequently in women than in men at younger ages but the gap between the sexes narrows in later life, which is due to reduced sexual intercourse in women and a higher incidence of bladder outlet obstruction secondary to benign prostatic hyperplasia in men (Eliopoulos, 2018). In older adults, structural abnormalities secondary to decreased bladder tone, neurogenic bladder (dysfunctional bladder) secondary to stroke, or autonomic neuropathy of diabetes may prevent complete emptying of the bladder and increase the risk of UTI (Eliopoulos, 2018). When indwelling catheters are used, the risk of UTI increases dramatically (Hagerty, Kertesz, Schmidt, et al., 2015). Older women often have incomplete emptying of the bladder and urinary stasis. In the absence of estrogen, postmenopausal women are susceptible to colonization and increased adherence of bacteria to the vagina and urethra. Oral or topical estrogen has been used to restore the glycogen content of vaginal epithelial cells and an acidic pH for some postmenopausal women with recurrent cystitis. The antibacterial activity of prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging. The use of catheterization or cystoscopy in evaluation or treatment for prostatic hyperplasia or carcinoma, strictures of the urethra, and neuropathic bladder may contribute to the higher incidence of UTIs in men. The incidence of bacteriuria also increases in men with confusion, dementia, or bowel or bladder incontinence. The most common cause of recurrent UTIs in older males is chronic bacterial prostatitis. Resection of the prostate gland may help reduce its incidence (see Chapter 59). Chart 55-3 Factors That Contribute to Urinary Tract Infection in Older Adults Cognitive impairment Frequent use of antimicrobial agents High incidence of multiple chronic medical conditions Immunocompromise Immobility and incomplete emptying of bladder Obstructed flow of urine (e.g., urethral strictures, neoplasms, or a clogged indwelling catheter) Adapted from Eliopoulos, C. (2018). Gerontological nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Chart 55-3 lists other factors that may contribute to UTI in older patients. Diligent hand hygiene, careful perineal care, and frequent toileting may decrease the incidence of UTIs. The organisms responsible for UTIs in the institutionalized older adult may differ from those found in patients residing in the community; this is thought to result in part from the frequent use of antibiotic agents by patients in long-term care facilities. E. coli is the most common organism seen in older patients in the community or hospital. However, patients with indwelling catheters are more likely to be infected with organisms such as Proteus, Klebsiella, Pseudomonas, or Staphylococcus. Patients who have been previously treated with antibiotics may be infected with Enterococcus species. Frequent reinfections are common in older adults. Early symptoms of UTI in older adults include burning, urgency, and fever (Eliopoulos, 2018). Some patients develop incontinence and delirium with the onset of a UTI. Antibiotics are prescribed when bacteriuria is present (Eliopoulos, 2018). Treatment regimens are generally the same as those for younger adults, although age-related changes in the intestinal absorption of medications and decreased kidney function and hepatic flow may necessitate alterations in the antimicrobial regimen. Kidney function must be monitored, and medication dosages should be altered accordingly. The nurse carefully monitors fluid intake and output. Increasing fluid intake is advisable, provided that the patient's cardiac status does not contraindicate this action (Eliopoulos, 2018). Assessment and Diagnostic Findings Results of various tests, such as bacterial colony counts, cellular studies, and urine cultures, help confirm the diagnosis of UTI. In an uncomplicated UTI, the strain of bacteria determines the antibiotic of choice (Grossman & Porth, 2014). Urine Cultures Urine cultures are useful for documenting a UTI and identifying the specific organism present. UTI is diagnosed by bacteria in the urine culture. A colony count greater than 100,000 CFU/mL. of urine on a clean-catch midstream or catheterized specimen indicates infection (Fischbach & Dunning, 2015). However, UTI and subsequent sepsis have occurred with lower bacterial colony counts. The presence of any bacteria in specimens obtained by suprapubic needle aspiration of the urinary bladder, straight catheterization (insertion of a tube into the urinary bladder), or during surgery or cystoscopy is considered clinically significant (Fischbach & Dunning, 2015). The following groups of patients should have urine cultures obtained when bacteriuria is present: All children All men (because of the likelihood of structural or functional abnormalities) Patients who have been recently hospitalized or who live in long-term care facilities Patients who have undergone recent instrumentation (including catheterization) of the urinary tract Patients with diabetes Patients with prolonged or persistent symptoms Patients with three or more UTIs in the previous year Women who are postmenopausal Women who are pregnant Women who are sexually active Women who have new sexual partners Women with a history of compromised immune function or renal problems Cellular Studies Microscopic hematuria is present in about half of patients with an acute UTI (see Chapter 53). Pyuria (white blood cells [WBCs] in the urine) occurs in all patients with UTI; however, it is not specific for bacterial infection. Pyuria can also be seen with kidney stones, interstitial nephritis, and renal tuberculosis. Other Studies A multiple-test dipstick often includes testing for WBCs, known as the leukocyte esterase test, and nitrite testing (Grossman & Porth, 2014). Tests for sexually transmitted infections may be performed because acute urethritis caused by sexually transmitted organisms (i.e., Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex) or acute vaginitis infections (caused by Trichomonas or Candida species) may be responsible for symptoms similar to those of UTIs. X-ray images, computed tomography (CT) scan, ultrasonography, and kidney scans are useful diagnostic tools. A CT scan may detect pyelonephritis or abscesses. Ultrasonography and kidney scans are extremely sensitive for detecting obstruction, abscesses, tumors, and cysts (Grossman & Porth, 2014). Medical Management Management of UTIs typically involves pharmacologic therapy and patient education. Various prescribed medication regimens are used to treat UTI. Acute Pharmacologic Therapy The ideal medication for treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. The antibacterial agent should be affordable and should have few adverse effects and low resistance. Because the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3-day) regimens, or 7-day regimens (Hopkins et al., 2014). The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment. Medications commonly used to treat UTIs are listed in Table 55-1. Regardless of the regimen prescribed, the patient is instructed to take all doses prescribed, even if relief of symptoms occurs promptly. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Hospitalization and intravenous (IV) antibiotics are occasionally necessary (Hopkins et al., 2014). (Hinkle 1616-1619) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file. Long-Term Pharmacologic Therapy Although brief pharmacologic treatment of UTIs for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTIs. Infections that recur within 2 weeks of therapy do so because organisms of the original offending strain remain. Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial treatment was inadequate or given for too short a time. Recurrent infections in men are usually caused by persistence of the same organism; further evaluation and treatment are indicated (Hopkins et al., 2014). If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. If there is no recurrence, medication is taken every other night for 6 to 7 months. Long-term use of antimicrobial agents decreases the risk of reinfection and may be indicated in patients with recurrent infections. If recurrence is caused by persistent bacteria from preceding infections, the cause (i.e., kidney stone, abscess), if known, must be treated. After treatment and sterilization of the urine, low-dose prophylactic therapy (trimethoprim with or without sulfamethoxazole) each night at bedtime may be prescribed (Hopkins et al., 2014). Daily intake of cranberry juice can help prevent and control symptoms of UTI (Bass-Ware, Weed, Johnson, et al., 2014; Hopkins et al., 2014). One group of researchers reported that daily consumption of cranberry juice over an 8-week period decreased symptoms (i.e., urgency, frequency, nocturia, dysuria, and pain) in women diagnosed with a UTI in an ambulatory setting (Bass-Ware, et al., 2014). (Hinkle 1619) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Infections of the urinary tract

Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally classified as infections involving the upper or lower urinary tract and further classified as uncomplicated or complicated, depending on other patient-related conditions (see Chart 55-1). Lower UTIs include bacterial cystitis (inflammation of the urinary bladder), bacterial prostatitis (inflammation of the prostate gland), and bacterial urethritis (inflammation of the urethra). Acute or chronic nonbacterial causes of inflammation in any of these areas can be misdiagnosed as bacterial infections. Upper UTIs are much less common and include acute or chronic pyelonephritis (inflammation of the renal pelvis), interstitial nephritis (inflammation of the kidney), and kidney abscesses. Upper and lower UTIs are further classified as uncomplicated or complicated, depending on whether the UTI is recurrent and the duration of the infection. Most uncomplicated UTIs are community acquired (Hopkins, McCroskey, Reeves, et al., 2014). Complicated UTIs usually occur in people with urologic abnormalities or recent catheterization and are often acquired during hospitalization. (Hinkle 1615-1616) A UTI is the second most common infection in the body. Most cases occur in women; one out of every five women in the United States will develop a UTI during her lifetime. The urinary tract is the most common site of nosocomial infection, accounting for greater than 40% of the total number reported by hospitals and affecting about 600,000 patients each year. In most of these hospital-acquired UTIs, instrumentation of the urinary tract or catheterization is the precipitating cause. More than 250,000 cases of acute pyelonephritis occur in the United States each year, with 100,000 patients requiring hospitalization. Approximately 8.1 million women are diagnosed with uncomplicated UTIs in the United States annually (Hopkins et al., 2014). (Hinkle 1616) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.