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Renal and urologic disorders encompass a wide spectrum of clinical problems. The diverse causes of these disorders may involve infectious, immunologic, obstructive, metabolic, collagen-vascular, traumatic, congenital, neoplastic, and neurologic mechanisms. This chapter discusses specific disorders of the kidneys, ureters, bladder, and urethra. Acute renal failure and chronic kidney disease are discussed in Chapter 47. Female reproductive problems are discussed in Chapter 54. Male genitourinary problems are discussed in Chapter 55.

TABLE 46-1

C o m m o n Microorganisms Causing Urinary Tract Infections

Pseudomonas Staphylococcus Serratia Candida albicans^

Escherichia coli' Enterococcus Klebsiella Enterobacter Proteus

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

Infectious and Inflammatory Disorders of the Urinary System

URINARY TRACT INFECTION
Urinary tract infections (UTIs) are the second most c o m m o n bacterial disease and the most c o m m o n bacterial infection in women, with at least one-third of women developing a UTI before the age of 24. During their lifetime, more than half of w o m e n will have a UTI, and up to 5 0 % of these will have another infection within a year. Pregnant women are at increased risk for UTIs. UTIs complicate up to 2 0 % of pregnancies and are responsible for 10% of all antepartum admissions. UTIs account for more than 8 million office visits per year and are associated with direct costs of $1.8 billion. M o r e than 100,000 people are hospitalized annually because of UTIs. More than 1 5 % of patients who develop gramnegative bacteremia die, and one third of these cases are caused by bacterial infections originating in the urinary tract.
1 2 1,3

CULTURAL AND DISPARITIES

ETHNIC

HEALTH

Urologic Disorders
Urinary tract calculi are more c o m m o n among whites than African Americans. * Jewish men have a high incidence of uric acid stones. Bladder cancer has a higher incidence among white men than African American men. In all ethnic groups, bladder cancer affects men about 3 times more often than w o m e n . Prostate cancer has a higher prevalence in African American men than white men. Urinary incontinence is underreported because culturally it is seen as a social hygiene problem causing patient embarrassment.

Inflammation of the urinary tract may be attributable to a variety of disorders, but bacterial infection is by far the most common. The bladder and its contents are free from bacteria in the majority of healthy persons. Nevertheless, a minority of otherwise healthy individuals, including many sexually active, young adult women and older w o m e n and men, have some bacteria colonizing the bladder. This condition is called asymptomatic bacteriuria and does not justify screening or treatment except in pregnant w o m e n . In contrast, an infection of the urinary system is diagnosed when bacterial invasion of the urinary tract occurs.
1 4

inflammation (usually due to infection) of the renal parenchyma and collecting system, cystitis indicates inflammation of the bladder wall, and urethritis means inflammation of the urethra. Urosepsis is a UTI that has spread into the systemic circulation and is a lifethreatening condition requiring emergency treatment. Classifying a UTI as complicated or uncomplicated is also useful. ' Uncomplicated infections are those that occur in an otherwise normal urinary tract and usually only involve the bladder. Complicated infections include those with coexisting presence of obstruction, stones, or catheters; existing diabetes or neurologic diseases; pregnancy-induced changes; or an infection that is recurrent. T h e individual with a complicated infection is at risk for pyelonephritis, urosepsis, and renal damage.
1 3 2

Escherichia coli (Table 46-1) is the most c o m m o n pathogen causing a UTI, and is primarily seen in women. Bacterial counts of 10 colony-forming units per milliliter (CFU/ml) or higher typically indicate a clinically significant UTI. However, counts as low as 10 to 10 CFU/ml in a person with signs and symptoms are indicative of UTI. Although fungal and parasitic infections may also cause UTIs, they are uncommon. UTIs from these causes are sometimes observed in patients who are immunosuppressed, have diabetes mellitus, or have undergone multiple courses of antibiotic therapy. They also may be seen in persons living in or having traveled to certain third-world countries.
5 2 3

Classification
Several classification systems can be used for UTIs. ' For example, a UTI can be broadly classified as an upper or lower UTI according to its location within the urinary system (Fig. 46-1). Infection of the upper urinary tract (involving the renal parenchyma, pelvis, and ureters) typically causes fever, chills, and flank pain, whereas a UTI confined to the lower urinary tract does not usually have systemic manifestations. Specific terms are used to further delineate the location of a UTI or inflammation. For example, pyelonephritis implies
1 3

UTIs can also be classified according to their natural history. An initial infection (sometimes called a first or isolated infection) refers to an uncomplicated U T I in a person who has never had an infection or experiences one that is remote from any previous UTI (usually separated by a period of years). In contrast, a recurrent UTI is a reinfection caused by a second pathogen in a person who experienced a previous infection that was successfully eradicated. If a recurrent UTI occurs because the original infection is not adequately eradicated, it is classified as unresolved bacteriuria or bacterial persistence. Unresolved bacteriuria occurs when bacteria are initially resistant to the antibiotic used to treat an infection, when the antibiotic agent fails to achieve adequate concentrations in the urine or bloodstream to kill bacteria, or when the drug is discontinued before the underlying bacteriuria is completely eradicated. Bacterial persistence also may occur when bacteria develop resistance to the antibiotic agent selected for treatment or when a foreign body in the urinary system serves as a harbor or anchor allowing bacteria to survive despite appropriate therapy.
3,5

TABLE 46-2

Predisposing Factors to Urinary Tract Infections

Factors Increasing Urinary Stasis

Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH) Extrinsic obstruction (tumor, fibrosis compressing urinary tract) Urinary retention (including neurogenic bladder and low bladder wall compliance) Renal impairment

Foreign Bodies
Urinary tract calculi Catheters (indwelling, external condom catheter, ureteral stent, nephrostomy tube, intermittent catheterization) Urinary tract instrumentation (cystoscopy, urodynamics)

Anatomic Factors
Congenital defects leading to obstruction or urinary stasis Fistula (abnormal opening) exposing urinary stream to skin, vagina, or fecal stream Shorter female urethra and colonization from normal vaginal flora Obesity

Factors Compromising Immune Response

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

Aging Human immunodeficiency virus infection Diabetes mellitus

Functional Disorders

Etiology and Pathophysiology

T h e urinary tract above the urethra is normally sterile. Several mechanical and physiologic defense mechanisms assist in maintaining sterility and preventing UTIs. These defenses include normal voiding with complete emptying of the bladder, ureterovesical junction competence, and peristaltic activity that propels urine toward the bladder. Antibacterial characteristics of urine are maintained by an acidic pH ( < 6 . 0 ) , high urea concentration, and abundant glycoproteins that interfere with the growth of bacteria. An alteration in any of these defense mechanisms increases the risk of contracting a UTI. Table 46-2 lists predisposing factors to U T I s . Menopause also appears to be a factor in the incidence of UTI in women. Before menopause, glycogen-rich epithelial cells and the normal bacterial flora Lactobacillus keep the vaginal pH acidic (3.5 to 4.5). This acidic environment helps to prevent the overgrowth of organisms that usually only proliferate in a pH above 4.5. In postmenopausal women, lower estrogen levels cause vaginal atrophy, a decrease in vaginal lactobacilli, and an increase in vaginal pH. This leads to an overgrowth of other organisms, specifically E. coli, and increases susceptibility to UTIs. Giving women low-dose intravaginal estrogen replacement acidifies the vagina and may be effective in treating recurrent U T I .
6

Constipation Voiding dysfunction with detrusor sphincter dyssynergia

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

BPH, Benign prostatic hyperplasia.

"milking" of bacteria from the vagina and perineum and may cause minor urethral trauma that predisposes women to UTIs. Rarely do UTIs result from a hematogenous route, where blood-borne bacteria secondarily invade the kidneys, ureters, or bladder from elsewhere in the body. For a kidney infection to occur from hematogenous transmission, there must be prior injury to the urinary tract, such as obstruction of the ureter, damage caused by stones, or renal scars. An important source of UTIs is hospital-acquired, or nosocomial, infections, which account for 3 1 % of all nosocomial infections. The cause of nosocomial infection is often E. coli and, less frequently, Pseudomonas organisms. Catheter-acquired urinary tract infections (CAUTIs) are the most c o m m o n nosocomial infections and are caused by development of bacterial biofilms that are found on the inner surface of the catheter. Most often these infections are underrecognized and undertreated, leading to complications such as renal abscesses, arthritis, epididymitis, periurethral gland infections, and bacteremia.
7 8

The organisms that usually cause UTIs are introduced via the ascending route from the urethra and originate in the perineum. Other less common routes are via the bloodstream or lymphatic system. Most infections are due to gram-negative bacilli normally found in the gastrointestinal (GI) tract, although gram-positive organisms such as streptococci, enterococci, and Staphylococcus saprophyticus can also cause urinary infections. A c o m m o n factor contributing to ascending infection is urologic instrumentation (e.g., catheterization, cystoscopic examinations). Instrumentation allows bacteria that are normally present at the opening of the urethra to enter the urethra or bladder. Sexual intercourse promotes

Clinical M a n i f e s t a t i o n s
Lower urinary tract symptoms (LUTS) are experienced in patients w h o have UTIs of the upper urinary tracts, as well as those confined to the lower tract. These symptoms are related to either bladder storage or bladder emptying. These symptoms are defined in Table 46-3.
9

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TABLE 46-3

Lower Urinary Tract S y m p t o m s (LUTS)

Emptying Symptoms
Weak urinary stream Hesitancy difficulty starting the urine stream resulting in a delay between initiation of urination by relaxation of the urethral sphincter and when urine stream actually begins. Intermittency interruption of the urinary stream while voiding. Postvoid dribblingurine loss after completion of voiding. Urinary retention or incomplete emptying inability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra. Can be acute or chronic. Dysuria difficulty voiding. Pain on urination

Storage Symptoms
Urinary frequency an abnormally frequent (usually >8 times in a 24-hr period) desire to void, often of only small quantities (e.g., less than 200 ml). Urgency a sudden, strong or intense desire to void immediately, usually accompanied by frequency. Incontinence involuntary or unwanted loss or leakage of urine. Nocturia waking up 2 or more times at night because of the need or urge to void. Nocturnal enuresis complaint of loss of urine during sleep. In children, it is called bedwetting.

These symptoms include dysuria, frequent urination (more often than every 2 hours), urgency, and suprapubic discomfort or pressure. The urine may contain grossly visible blood (hematuria) or sediment, giving it a cloudy appearance. Flank pain, chills, and the presence of a fever indicate an infection involving the upper urinary tract (pyelonephritis). It is important to remember that these symptoms, considered characteristic of a UTI, are often absent in older adults. Older adults tend to experience nonlocalized abdominal discomfort rather than dysuria and suprapubic p a i n . In addition, they may present with cognitive impairment or generalized clinical deterioration. Because older adults are less likely to experience a fever with a UTI, the value of body temperature as an indicator of a U T I is unreliable. Patients over age 80 years may experience a slight decline in temperature. People with significant bacteriuria may have no symptoms or may have nonspecific symptoms such as fatigue or anorexia.
10

A voided midstream technique yielding a clean-catch urine sample is preferred for obtaining a urine culture in most circumstances. For women, this is done by spreading the labia and wiping the periurethral area from front to back using a moistened, clean gauze sponge (no antiseptic is used as it could contaminate the specimen and cause false positives), keeping the labia spread and collecting the specimen 1 to 2 seconds after voiding starts. For men, the glans penis is wiped around the urethra. The specimen is collected 1 to 2 seconds after voiding begins. Urine should be refrigerated immediately on collection and should be cultured within 24 hours of refrigeration. However, a specimen obtained by catheterization or suprapubic needle aspiration provides more accurate results and may be necessary when an adequate clean-catch specimen cannot be readily obtained. A urine culture is accompanied by sensitivity testing to determine the bacteria's susceptibility to a variety of antibiotic drugs. The results of this test allow the health care provider to select an antibiotic known to be capable of destroying the bacterial strain producing a UTI in a specific patient. Imaging studies of the urinary tract are indicated in selected cases. For example, an intravenous pyelogram (IVP) or abdominal computed tomography (CT) scan may be obtained when obstruction of the urinary system is suspected of causing a UTI. In patients with recurrent UTIs, renal ultrasound is the preferred urinary tract imaging technique because it is noninvasive, easy to perform, and relatively inexpensive. Studies have shown that patients with symptoms can effectively diagnose their own UTIs and self-initiate treatments with the same success rate as physicians.
2,3

Collaborative Care a n d Drug Therapy

Once a U T I has been diagnosed, appropriate antimicrobial therapy is initiated. An antibiotic may be selected based on the health care provider's best judgment (empiric therapy) or the results of sensitivity testing. The collaborative care and drug therapy of cystitis are summarized in Table 46-4. Uncomplicated cystitis can be treated by a short-term course of antibiotics, typically for 1 to 3 days. In contrast, complicated UTIs require longer term treatment, lasting 7 to 14 days or even l o n g e r . Because many residents of long-term care facilities (approximately 3 0 % to 50%), especially females, have chronic asymptomatic bacteriuria, the researchbased literature suggests treating only symptomatic UTIs. Therefore continued bacteriuria without clinical symptoms does not warrant repeat or continued antibiotic therapy.
25 7

Multiple factors may produce L U T S similar to a UTI. For example, patients with bladder tumors or those receiving intravesical chemotherapy or pelvic radiation usually experience urinary frequency, urgency, and dysuria. Interstitial cystitis, a chronic inflammatory condition of unknown etiology, also produces urinary symptoms that are sometimes confused with a UTI. (Interstitial cystitis is discussed later in this chapter.)

Diagnostic Studies
Dipstick urinalysis should be obtained initially to identify the presence of nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in W B C s indicating pyuria). These findings can be confirmed by microscopic urinalys i s . Following confirmation of bacteriuria and pyuria, a urine culture may be obtained. A urine culture is indicated in complicated or nosocomial UTIs, persistent bacteria, or frequently recurring UTIs (more than two to three episodes per year). Urine also may be cultured when the infection is unresponsive to empiric therapy or the diagnosis is questionable.
11

Trimethoprim/sulfamethoxazole (TMP/SMX) or nitrofurantoin (Macrodantin) is often used to empirically treat uncomplicated or initial UTIs. T M P / S M X has the advantages of being relatively inexpensive and being taken twice daily. The disadvantage is that E. coli resistance to T M P / S M X is an increasing problem across the United States. Nitrofurantoin is normally given 3 to 4 times daily, but a long-acting preparation (Macrobid) is available that is taken twice daily. However, long-term use of nitrofurantoin can result in pulmonary fibrosis and neuropathies. Ampicillin and amoxicillin are not frequently selected when empirically treating a noncomplicated UTI because they must be administered 3 to 4 times daily. In addition to these agents, the fluoroquinolones (including ciprofloxacin [Cipro], levofloxacin [Levaquin], norfloxacin [Noroxin], ofloxacin [Floxin], and gatifloxacin [Tequin]) may be used to treat complicated UTIs. In patients with UTIs secondary to fungi, amphotericin or fluconazole are preferred therapy.
3

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TABLE 46-4

COLLABORATIVE CARE Urinary Tract Infection

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

Are Prophylactic Antibiotics Effective for Jrinary Tract Infection?

In w o m e n (P), is long-term prophylactic antibiotic use (I) more effective than placebo (C) in preventing recurrent urinary tract infections (O)?
n a "1 LI r- - J

Collaborative Therapy Uncomplicated UTI

Antibiotic: trimethoprim-sulfamethoxazole (TMP-SMX) (Bactrim, Septra), or trimethoprim alone in patients with sulfa allergy; nitrofurantoin (Macrodantin, Macrobid) Adequate fluid intake Urinary analgesic: phenazopyridine (Pyridium) or combination agent (e.g., Urised) Counseling about risk of recurrence and reduction of risk factors

Systematic review of randomized controlled trials (RCTs)

j
10 RCTs (n = 430 women) comparing antibiotic use for 6 to 12 months against a placebo for recurrent urinary tract infections (UTI). Recurrence is defined as three or more UTI episodes during a 12-month period. j Antibiotics reduced the number of UTI recurrences in pre- and I postmenopausal w o m e n with recurrent UTI.

Recurrent, Uncomplicated UTI

Repeat urinalysis and consider urine culture and sensitivity testing Antibiotic: 3- to 5-day treatment regimen of TMP-SMX, nitrofurantoin Sensitivity-guided antibiotic (ampicillin, amoxicillin, first-generation cephalosporin, fluoroquinolone) Consider postcoital antibiotic prophylaxis (TMP-SMX, nitrofurantoin, cephalexin) Advise on pre- and postcoital voiding Consideration of 3- to 6-month trial of (suppressive) prophylactic antibiotics Adequate fluid intake Cranberry or lingonberry juice (200-750 ml or equivalent tablets daily) Urinary analgesic such as phenazopyridine (Pyridium) or combination agent (e.g., Urised) Counseling about risk of recurrence and reduction of risk factors Imaging study of urinary tract in selected cases IVP, Intravenous pyelogram; UTI, urinary tract infection.

' Antibiotic group had higher incidence of side effects, including vaginal itching, skin rash, and nausea.

Conclusions
Prophylactic antibiotic administration in women who experience recurrent UTIs reduces recurrence.

Implications for Nursing Practice

Patient treatment preference should be considered when weighing the discomfort of recurrent UTIs and the adverse effects of prophylactic antibiotics, UTI prophylaxis for longer than 12 months has not been studied.

Reference for Evidence Albert X, Huertas I, Pereiro I, et al: Antibiotics for preventing recurrent urinary tract infection in non-pregnant women, Cochrane Database Syst Rev 3, 2004. PICO: P, Patient population of interest; /, intervention or area of interest; C, comparison of interest or comparison group; O, outcome(s) of interest (see p. 6).

Drug Alert - Nitrofurantoin (Furadantin, Macrodantin)

Avoid sunlight; use sunscreen, wear protective clothing. Notify health care provider if fever, chills, cough, chest pain, dyspnea, rash, or numbness or tingling of fingers or toes develops.

limited because of the risk of antibiotic resistance, which ultimately leads to breakthrough infections with increasingly virulent pathogens.
1,3

A number of over-the-counter (OTC) or prescription drugs may be used in combination with antibiotic agents to relieve the discomfort associated with a U T I . Phenazopyridine (Pyridium) is an OTC drug that provides a soothing effect on the urinary tract mucosa. It also stains the urine a reddish orange that may be mistaken for blood in the urine, and it may permanently stain underclothing. Although this drug is typically effective in relieving the transient acute discomfort associated with a U T I , patients should be advised to avoid long-term use of phenazopyridine because it can produce hemolytic anemia. Combination agents such as Urised (methenamine, phenyl salicylate, methylene blue, benzoic acid, atropine, and hyoscyamine) may also be used to relieve the symptoms associated with a U T I . The patient taking a combination agent such as Urised should be advised that preparations containing methylene blue are expected to tint the urine blue or green. Prophylactic or suppressive antibiotics are sometimes administered to patients who experience repeated UTIs. A low dose of T M P / S M X , nitrofurantoin, or another antibiotic may be administered on a daily basis in an attempt to prevent recurring UTIs, or a single dose may be taken before an event likely to provoke a UTI, such as before having sexual intercourse. Although suppressive therapy is often effective on a short-term basis, this strategy is

NURSING MANAGEMENT URINARY TRACT INFECTION Nursing Assessment

Subjective and objective data that should be obtained from a patient with a UTI are presented in Table 46-5.

Nursing

Diagnoses

Nursing diagnoses for the patient with a U T I may include, but are not limited to, those presented in N C P 4 6 - 1 .

Planning

The overall goals are that the patient with a U T I will have (1) relief from bothersome L U T S , (2) prevention of upper urinary tract involvement, and (3) prevention of recurrence.

Nursing

Implementation

Health Promotion. Health promotion measures include recognizing individuals who are at risk for a UTI. Debilitated persons, older adults, patients with underlying diseases (e.g., cancer, human immunodeficiency virus [HIV], or diabetes mellitus) that compromise host immune responses, and patients treated with immuno-

Chapter 46

Renal andUrologic Problems

1159

TABLE 46-5

NURSING ASSESSMENT Urinary Tract Infection

Subjective Data Important Health

Information

Past health history: Previous urinary tract infections; urinary calculi, stasis, reflux, strictures, or retention; neurogenic bladder; pregnancy; benign prostatic hyperplasia; sexually transmitted disease; bladder cancer Medications: Use of antibiotics, anticholinergics, antispasmodics Surgery or other treatments: Recent urologic instrumentation (catheterization, cystoscopy, surgery)

Functional Health Patterns

Health perception-health management: Urinary hygiene practices; lassitude, malaise Nutritional-metabolic: Nausea, vomiting, and anorexia; chills Elimination: Urinary frequency, urgency, hesitancy; dysuria, nocturia Cognitive-perceptual: Suprapubic or low back pain, costovertebral tenderness; bladder spasms, dysuria, burning on urination Sexuality-reproductive: Multiple sex partners (women), use of spermicidal agents or contraceptive diaphragm (women)

Objective Data General

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

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

Possible Findings
Leukocytosis; urinalysis positive for bacteria, pyuria, RBCs, and WBCs; positive urine culture; IVP, CT scan, ultrasound, voiding cystourethrogram, and cystoscopy demonstrating abnormalities of urinary tract CT, Computed tomography; IVP, intravenous pyelogram; RBCs, red blood cells; WBCs, white blood cells.

suppressive drugs or corticosteroids are at high risk for UTIs. Especially for these individuals, health promotion activities can help decrease the frequency of infections and promote early detection of infection. Health promotion activities include teaching preventive measures such as (1) emptying the bladder regularly and completely, (2) evacuating the bowel regularly, (3) wiping the perineal area from front to back after urination and defecation, and (4) drinking an adequate amount of liquid each day. The recommended daily liquid intake for the ambulatory adult is approximately 15 ml per pound of body weight per day. Thus a 150-pound person would require 2250 ml each day. Because the person will obtain approximately 2 0 % of this fluid from food, this leaves 1800 ml obtained by drinking, or just over seven 8-ounce glasses of fluid. Daily intake of cranberry or lingonberry juice or cranberry essence tablets may reduce the risk of U T I s . It is thought that enzymes found in cranberries inhibit attachment of urinary pathogens (especially E. coli) to the bladder epithelium. Suppressive antibiotics are not generally recommended to prevent UTIs, but it is important to teach the patient to seek early treatment once symptoms occur.
12

The nurse can play a major role in the prevention of nosocomial infections. Avoidance of unnecessary catheterization and early removal of indwelling catheters are the most effective means for reducing nosocomial UTIs. All patients undergoing instrumentation of the urinary tract are at risk for developing a nosocomial UTI. Aseptic technique must always be followed during these procedures. Washing hands before and after contact with each patient

and wearing gloves for care involving the urinary system are especially important. W h e n a catheter has been inserted, special measures must be employed as explained in the section on urethral catheterization later in this chapter. Routine and thorough perineal hygiene is important for all hospitalized patients, especially when a bedpan is used, following a bowel movement, and/or if fecal incontinence is present. Incontinent episodes should be avoided by answering the call light quickly or offering the bedpan or urinal at frequent intervals to the bedridden patient. Acute Intervention. Acute intervention for a patient with a UTI includes ensuring adequate fluid intake if it is not contraindicated. It is sometimes difficult to get the patient to maintain an adequate fluid intake because the person may think it will worsen the discomfort and frequency associated with a UTI. The patient needs to be told that fluids will increase frequency of urination at first but will also dilute the urine, making the bladder less irritable. Fluids will help flush out bacteria before they have a chance to colonize in the bladder. Caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages should be avoided because they are potential bladder irritants. Application of local heat to the suprapubic area or lower back may relieve the discomfort associated with a UTI. The patient can be advised to apply a heating pad (turned to its lowest setting) against the back or suprapubic area. A warm shower or sitting in a tub of warm water filled above the waist can also be effective in providing temporary relief. T h e patient should be instructed about the prescribed drug therapy, including side effects. The nurse should emphasize the importance of taking the full course of antibiotics. Often patients stop antibiotic therapy once s y m p t o m s disappear. This practice can lead to inadequate treatment and recurrence of infection or to bacterial resistance to antibiotics. Sometimes a second drug or a reduced dose of drug is ordered after the initial course to suppress bacterial growth in patients susceptible to recurrent U T I . T h e patient should be instructed to watch for any changes in the color or consistency of the urine and a decrease in or cessation of s y m p t o m s as a sign of the effectiveness of therapy. T h e patient should be counseled that (1) persistence of bothersome L U T S beyond the antibiotic treatment course, (2) the onset of flank pain, or (3) fever should be reported promptly to a health care provider. Ambulatory and Home Care. Home care for the patient with a U T I should emphasize the patient's compliance with the drug regimen. The nurse's responsibility is to teach the patient about the need for ongoing care (Table 46-6). This includes taking antimicrobial drugs as ordered, maintaining adequate daily fluid intake, regular voiding (approximately every 3 to 4 hours), urinating before and after intercourse, and temporarily discontinuing the use of a diaphragm (if used). The patient must understand the need for follow-up care if symptoms do not resolve, worsen, or return once treatment is completed. Recurrent symptoms because of bacterial persistence or inadequate treatment typically occur within 1 to 2 weeks after completion of therapy. If the patient has been compliant with treatment, a relapse indicates the need for further evaluation.

Evaluation

The expected outcomes for the patient with a UTI are presented in NCP 46-1.

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NURSING CARE PLAN 46-1

11 Patient with a Urinary Tract Infection

NURSING DIAGNOSIS Impaired urinary elimination related to effects of urinary tract infection ( U T 1 ) as evidenced by pain and burning on urination; flank, suprapubic, and/or lower back pain; urgency; frequency; nocturia; or hematuria

PATIENT GOALS

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

Urinary Elimination Pain with urination Burning with urination _ Urinary frequency Urgency with urination. Nocturia Visible blood in urine _ Measurement Scale
1= 2= 3= 4= 5= Severe Substantial Moderate Mild None

Urinary Elimination Management Monitor urinary elimination, including frequency, consistency, odor, volume, and color, to evaluate elimination status. Obtain midstream voided specimen for culture and sensitivity (as appropriate) to determine pathogen causing UTI or to monitor effectiveness of treatment. Teach patient to drink eight ounces of liquid with meals, between meals, and in early evening to prevent dehydration, relieve bladder irritability, and decrease bacterial colonization. Pain Management Perform a comprehensive assessment of pain to include location, characteristics, onset/ duration, frequency, quality, intensity or severity, and precipitating factors to establish history and baseline pain level. Provide the patient optimal pain relief with prescribed analgesics (such as phenazopyridine [Pyridium]) or combination agents (e.g., Urised) to promote comfort. Teach the use of nonpharmacologic techniques (e.g., heating pad to suprapubic area or lower back, warm showers) along with other relief measures to supplement pain medication and increase pain relief. Ineffective therapeutic regimen management related to lack of knowledge regarding treatment regimen and prevention of recurrent infections as evidenced by verbalization of desire to manage treatment of illness and prevent recurrence

NURSING DIAGNOSIS

PATIENT COALS

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

OUTGO
Knowledge: Treatment Regimen * Description of specific disease process _ Description of rationale for treatment regimen . * Description of self-care responsibilities for ongoing treatment Description of expected effects of treatment Description of prescribed medications _ Measurement Scale
1 ~ None 2 = Limited 3 Moderate 4 = Substantial 5 == Extensive

11 i\ iVH i! 11M111 ii11 \n Mil\l\ Mi iU^tISm3Wlfmmm!\

Teaching: Disease Process " ' Appraise patient's current level of knowledge related to specific disease process to plan individualized teaching, o Explain pathophysiology of the disease and how it relates to anatomy and physiology. * Describe rationale behind management/therapy/treatment recommendations to promote compliance with treatment. ' Describe possible chronic complications to emphasize the need for completion of treatment. Teaching: Prescribed Medication * Instruct patient on the purpose and action of each medication. * Instruct patient on possible adverse effects of each medication so patient can identify problems. * Instruct patient on appropriate actions to take if side effects occur to prevent serious problems.

to.,:

,.;-3!

Potential Complications " Anticipate potential for urosepsis in patients at risk. Report deviations from acceptable parameters. Carry out appropriate medical and nursing interventions.

Urosepsis (bacteriuria and bacteremia) related to systemic extension of UTI Monitor vital signs and for changes in mental status in patients at risk (immunocompromised, elderly, those with frequent urinary system instrumentation or anatomic abnormalities) to detect inadequate tissue perfusion. * Report abnormalities such as hyper- or hypothermia; decreasing blood pressure; rapid pulse and respirations; and warm, flushed skin as indicators of septic shock resulting from urosepsis. * Monitor platelet levels and coagulation function tests because alterations indicate bleeding tendencies.

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TABLE 46-6

PATIENT AND FAMILY TEACHING GUIDE Urinary Tract Infection

The following are important to teach to the patient with a UTI to prevent recurrence: 1. Explain importance of taking all antibiotics as prescribed. Symptoms may improve after 1 to 2 days of therapy, but organisms may still be present. 2. Instruct the patient on appropriate hygiene, including the following: Careful cleansing of perineal region by separating the labia when cleansing Wiping from front to back after urinating Cleansing with warm soapy water after each bowel movement 3. Explain the importance of emptying the bladder before and after sexual intercourse. 4. Instruct the patient to urinate regularly, approximately every 3 to 4 hours during the day. 5. Instruct the patient about the need to maintain adequate fluid intake. 6. Instruct the patient to avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. 7. Advise the patient to report symptoms or signs of recurrent UTI (e.g., fever, cloudy urine, pain on urination, urgency, frequency). 8. Suggest possible use of unsweetened cranberry juice 8 oz three times a day or extract tablets 300 to 400 mg/day for UTI prevention. UTI, Urinary tract infection.

FIG. 4 6 - 2

Acute pyelonephritis. Cortical surface shows grayish white a r e a ; :"

inflammation and abscess formation.

urinary urgency, and frequency. Costovertebral tenderness (costovertebral angle [CVA] pain) is typically present on the affected side. The clinical manifestations usually subside within a few days, even without specific therapy, but bacteriuria and pyuria usually persist. Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria. W B C casts may be found in the urine, indicating involvement of the renal parenchyma. A complete blood count will show leukocytosis and a shift to the left with an increase in immature neutrophils (bands). Urine cultures must be obtained when pyelonephritis is suspected. In patients with more severe illness who are hospitalized, blood cultures are also obtained. Imaging studies, such as an IVP or CT scan, requiring intravenous (IV) injection of contrast materials are usually not obtained in the early stages of pyelonephritis to prevent the possible spread of infection. Alternatively, ultrasonography of the urinary system may be obtained to identify anatomic abnormalities, hydronephrosis, renal abscesses, or the presence of an obstructing stone. Imaging studies are also used to assess for complications of pyelonephritis such as impaired renal function, scarring, chronic pyelonephritis, or abscesses. Urosepsis is characterized by bacteriuria and bacteremia (presence of bacteria in blood). If bacteremia is a possibility, close observation and vital sign monitoring are essential. Prompt recognition and treatment of septic shock may prevent irreversible dar. a i or death.

ACUTE PYELONEPHRITIS

Etiology and Pathophysiology

Pyelonephritis is an inflammation of the renal parenchyma (Fig. 46-2) and collecting system (including the renal pelvis). The most c o m m o n cause is bacterial infection, but fungi, protozoa, or viruses sometimes infect the kidney. Urosepsis is a systemic infection arising from a urologic source. Its prompt diagnosis and effective treatment are critical because it can lead to septic shock and death in 1 5 % of cases unless promptly eradicated. Septic shock is the outcome of unresolved bacteremia involving a gram-negative o r g a n i s m . (Septic shock is discussed in Chapter 67.) Pyelonephritis usually begins with colonization and infection of the lower urinary tract via the ascending urethral route. Bacteria normally found in the intestinal tract, such as E. coli, Proteus, Klebsiella, or Enterobacter species, frequently cause pyelonephritis. A preexisting factor is often present, such as vesicoureteral reflux (retrograde or backward movement of urine from lower to upper urinary tract) or dysfunction of lower urinary tract function such as obstruction from benign prostatic hyperplasia (BPH), a stricture, or urinary stone. In residents of long-term care facilities, urinary tract catheterization and the use of indwelling catheters is a c o m m o n cause of pyelonephritis and urosepsis. Acute pyelonephritis commonly starts in the renal medulla and spreads to the adjacent cortex. One of the most important risk factors for acute pyelonephritis is pregnancy-induced physiologic changes in the urinary system. Recurring episodes of pyelonephritis, especially in the presence of obstructive abnormalities, can lead to a scarred, poorly functioning kidney and a condition called chronic pyelonephritis.
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Collaborative Care and Drug Therapy

The diagnostic tests and collaborative therapy of acute pyelonephritis are summarized in Table 46-7. Patients with severe infections or complicating factors such as nausea and vomiting with dehydration require hospital admission. The patient with mild symptoms may be treated as an outpatient with antibiotics for 14 to 21 days (see Table 46-7). Parenteral antibiotics are often given initially in the hospital to rapidly estabiis serum and urinary drug levels. When initial treatment resoh es acute symptoms and the patient is able to tolerate oral fluids and drugs, the person may be discharged on a regimen of oral antibiotics for an additional 14 to 21 days. Symptoms and signs typically improve or resolve within 48 to 72 hours after starting therapy.
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Clinical Manifestations and Diagnostic Studies

The clinical manifestations of acute pyelonephritis vary from mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank pain, and the L U T S characteristic of cystitis, including dysuria,

Relapses may be treated with a 6-week course of antibiotics Reinfections may be treated as individual episodes of disease or