UROLOGY Infection & Inflammatory Disorders n40% nosocomial nEscherichia coli; immunosuppress, DM, mult antibiotics -viral, fungal, parasites nComplicated- coexisting stones, DM, neuro disease, obstructions, catheters nRelapse, reinfections UTI nDefense mechanisms nPredisposing factors nSources of UTI- ascending, gram -, nosocomial, abnormal urinary tract Cystitis nEtiology- anatomic structure & pathologic changes in females, older males, young children nS/S- frequency, urgency, suprapubic pain, foul smelling urine, pyuria, dysuria nAsymptomatic bacteriuria- hematuria, fatigue, anorexia, cognitive changes n Cystitis nDx: WBC in u/a, urine C&S, gram stain, eval of urinary tract nMeds: Bactrim, Septra, Cipro, Macrodantin, Keflex, Pyridium nSingle dose or 1-3 day therapy nUTI with fever, flank pain or chronic- longer therapy nProphylactic therapy Nursing Care: Cystitis nHealth promotion: identify hi risk pts, teaching fld I, hygiene, empty bladder freq nPrevent nosocomial infection nIncrease fld I, avoid bladder irritants, teach drug therapy & s/e, teach s/s UTI nFollow up care with urine C&S, can relapse in 1-2 weeks Acute Pyelonephritis nAcute or chronic inflamm of renal pelvis or parenchyma of kidney nInfection ascends from lower urin tract nOften, preexisting factor nChronic pyelonephritis- starts in medulla, spreads to cortex, heals, fibrosis, scars n Acute Pyelonephritis nS/S: mild lassitude, s/s cystitis, sudden fever, chills, vomiting, malaise, flank pain, costovertebral tenderness on affected side nCBC- leukocytosis, incr banded neutrophils, u/a- pyuria, bacteriuria, hematuria, wbc casts nBacteremia, septic shock Pyelonephritis nDx- u/a, C&S, Gram’s stain, WBC, blood C&S, flank pain, ultrasound, CT scan nConsider contributing factors, IVP later nAntibiotics 14-21 days, rx of relapse with 6 wks or prophylactic antibiotics nEvaluate with urine C&S Nursing Care: Pyelonephritis nHealth Promotion: stress reg med care nTeach: continue med, importance of follow-up urine C&S, s/s relapse, drink 8 glasses water minimum, rest nTreat s/s- hyperthermia, pain, see NCP 46-1 Chronic Pyelonephritis nPredisposing factors: chronic UTIs, obstruction, neurogenic bladder, vesicouretal reflux nChronic inflammation & scarring, renal pelvis & calyces dilated, deformed nDestruction of nephrons->renal insuff nEnd stage chronic renal failure Urethitis nS/S same as cystitis, discharge, urethra tender, bacteria in edematous urethral tissue & don’t appear in u/a nCauses: viral, Trichomonas & monilial infection, Chlamydia & gonorrhea nSplit urine C&S, C&S discharge nRx: antibiotics, sitz bath, proper cleansing, no vaginal deodorant, avoid sex n Urethral Syndrome nAcute urethral syndrome: dysuria, urgency, frequency with bacteriuria nBacteriuria: E. coli, enterococci, staph nChlamydia, gonorrhea if few bacteria nR/O vaginitis nTX depends on cause cystoscopy Renal Tuberculosis nSecondary to TB of lung, onset 5-8 later nInitially, no s/s, low fever, fatigue nLesions ulcerate, spread to bladder-> s/s cystitis; may calcify-> lumbar & iliac pain, hematuria, renal colic nDx: urine C&S, IVP nComplications: strictures, scarring renal parenchyma, renal failure n Glomerulonephritis nInflammation of glomerulus with tubular, interstitial & vascular changes nImmunologic, antibody induced injury nAnti-GBM antibodies stimulated by structural alteration of GBM or reaction to virus & results in deposits in GBM nAntibodies react with nonglomerular antigens & randomly deposited, look “lumpy bumpy” Glomerulonephritis nAccumulation of antibody, antigen, compliment in glomeruli-> tissue injury nCompliment activation-> leukocytes, release of histamine & vasoactive amines, clotting mechanism activated nS/S: hematuria, u/a has WBC, RBC, casts, proteinuria, elev BUN, creatinine Acute Poststreptococcal Glomerulonephritis (APSGN) n5-21 days after skin or throat infection nGroup A Beta hemolytic streptococci nAntibodies to strep develop->inflam-> decreased filtration of metabolic waste, & increased permeability protein nS/S: none or generalized edema, oliguria, hi BP, “rusty” hematuria, proteinuria, flank pain APSGN nDx: H&P, u/a, CBC, BUN, creat, albumin, ASO titer, renal biopsy nNsg Care: rest, Na & fld restriction, diuretics, antihypertensive meds, lo P diet, antibiotics if have strep nEncourage early tx of sore throat & skin lesions, teach good hygiene & take all antibiotics Rapidly Progressing Glomerulonephritis (RPGN) nRenal failure occurs within weeks nOccurs as compliment of inflammatory disease, complication of systemic disease (Lupus), idiopathic, or assoc with drugs (PCN) nManage fld overload, hi BP, uremia nDialysis & transplant but RPGN can reoccur Nephrotic Syndrome nCauses: glomerulonephritis, infections, multisystem diseases, neoplasms, allergens nS/S: periph edema, proteinuria, hi lipids, lo albumin, ascites, anasarca, altered immune response -> infection, hypocalcemia, loss of clotting factors-> hypercoagulability, thrombus formation esp R renal vein, PE Nephrotic Syndrome nTx: relieve edema, control disease nACE inhibitors, NSAIDs, lo Na diet, loop diuretic nLipid lowering agents nAnticoagulants if thrombus nCorticosteroids & Cytoxin Nursing Care nAssess edema: daily wt, I&O, measure girth nSkin care, prevents trauma->weeping nMonitor diuretic therapy, labs nLo protein-> malnourished, anorexic, lo Na & P diet; assess dietary needs, sm freq feedings nPrevent infection nAltered body image- psychol support Obstructive Uropathies nCauses- intrinsic, extrinsic, functional nSystem above level of obstruction is affected nLocation, duration, pressure, urinary stasis, infection affect severity of effects nObstruction distal to prostate or bladder neck->mucosal scarring & slower stream nObstruction at prostate or bladder neck-> tabeculation, diverticuli, incr pres, reflux urinary tract obstructions ivp hydronephrosis Urinary Tract Calculi nStone formation: genetic, metabolic, dietary, climatic, lifestyle, occupational nCalculus- stone & lithiasis- formation nTypes of stones- see table 46-12 nS/S occur where stone causes obstruction to urine flow; severe abd or flank pain, hematuria, renal colic, n/v, UTI s/s nPassing stone- intense, colicky pain, mild shock with cool, moist skin calculi sites in urinary tract Urinary Tract Calculi nDx: history, u/a, C&S, IVP, retrograde pyelogram, ultrasound, cystocopy, abd x-ray, CT, urine & serum levels of stone metabolites, BUN, Creat, urine ph nManage acute attack- treat pain, infection, obstruction nEval of composition of stone & prevent further formation of stones staghorn calculus Urinary Tract Calculi nIndications for endourologic, lithotripsy or surgery nCystoscopy nCystolitholapaxy nCystoscopic lithotripsy nUltrasonic, laser or electrohydraulic lithotripsy nPercutaneous nephrolithotomy Nursing Care nPrevention- esp pts on BR with urinary stasis, incr fld I minimum 2L/day, diet restrictions purine, oxalate calcium nSee NCP 46-2 nStrain all urine nPain management nTeaching- diet, flds, meds, test urine ph Strictures nCongenital or acquired nOccur at bladder neck, urethra, ureters nCauses: trauma, gonorrhea, urethral instruments, chronic infections, radiation, retroperitoneal abscess nTreatment : dilitation with catheter, drainage with catheter, surgery urinary tract obstructions Renal Trauma nBlunt trauma common- car accidents, sports, falls with injury to flank, abdomen or back nPenetrating – gunshots, stabbing nDx: history, hematuria, u/a, IVP with cystogram, ultrasound, CT, MRI nNsg Care: Monitor I&O, hematuria & nephrotoxic antibiotics, pain, s/s shock Nephrosclerosis nSclerosis of small arteries & arterioles-> decr bld flow-> patches of necrosis-> destruction of glomeruli & fibrosis nBenign nephrosclerosis due to hi BP, & arteriosclerosis nAccelerated or malignant due to malig hi BP, diastolic >130-> renal insuffic-> renal failure eventually nPrevention & rx: treat hypertension Renal Artery Stenosis nPartial occlusion renal a. due to atherosclerosis or fibromuscular hyperplasia nDx: renal arteriogram nRx: control BP, angioplasty, stints, surgical anastomoses bet kidney & spleenic artery or aorta Polycystic Renal Disease nGenetic, latent, s/s appear age 30-40 nCortex & medulla filled with cysts nS/S when cysts enlarge- abd or flank pain, palpable enlarged kidneys, UTI, hi BP, hematuria, 50% develop renal fail. nDx: H&P, CT, IVP, ultrasound nRx: prevent UTI, nephrectomy, genetic counseling polycystic kidney Medullary Cystic Disease nHereditary nRecessive form-> renal fail. before 20 nDominant form-> renal failure after 20 nAffects ability to concentrate urine nPolyuria, severe anemia, renal failure, metabolic acidosis, poor Na concentration Renal Problems in Metabolic & Connective Tissue Diseases nDiabetic neuropathy nGout nAmyloidosis nSystemic Lupus Erythematosus nScleroderma Renal Tumors nArise from cortex or pelvis, benign or malignant- adenocarcinoma nRisk factors- smoking, exposure to asbestos, gasoline, cadmium, phenacetin containing analgesics nS/S: wt loss, anemia, weakness, gross hematuria, flank pain, palpable mass nMetastasis- lungs, liver, long bones, renal vein & vena cava Renal Tumors nDx: IVP with nephrotomography, CT, MRI, angiogram, needle aspiration nStaging- Robson’s system nTx: nephrectomy, radiation palliatively, no chemo available, biologic therapy Bladder Cancer nMost common- transitional cell carcinoma, papillomatous nRisk factors: smoking, dyes used in rubber & cable industry, phenacetin-containing analgesics, women tx with Cytoxin for cervical cancer nChronic stones->risk for squamous cell bladder cancer Bladder Cancer nS/S: gross & painless hematuria, also dysuria, freq, urgency nDx: urine for cytology, bladder tumor antigens, IVP, ultrasound, MRI nDefinite dx by cystoscopy & biopsy nJewett-Strong-Marshall classification: superficial, invasive, metastatic Surgery: Bladder Cancer nTransurethral resection with fulgaration nLaser photocoagulation nOpen loop resection with fulgaration nPost-op care: increase fld I, I&O, avoid alcohol, analgesics, sitz baths, psychol support, reg follow ups & cystoscopies nRadical cystectomy Tx Bladder Cancer nRadiation therapy nChemotherapy: Vinblastine, Platinol, Adriamycin, Methotrexate nIntravesicular therapy: instill chemo into bladder via catheter nS/E: irritating voiding, hemorrhagic cystitis, decr WBC & platelets Urinary Incontinence nStress incontinence nUrge incontinence nOverflow incontinence nReflux incontinence nIncontinence after trauma or surgery nFunctional incontinence Neurogenic Bladder nBladder dysfunction from CNS neurologic disorder nTumors, spinal cord injury, CVA, MS, diabetic neuropathy nFailure to store, empty or both nDysfunction of bladder or urethra nLocation- whether it affects brain or spinal cord n Causes of Urinary Retention nAntihypertensives- Aldomet, Apresoline nAntiparkinsonian- Levodopa nAntihistamines nAnticolinergics- Atropine nAntispasmodics nSedatives & spinal anesthesia nUrethral obstruction nPsychological Collaborative Care nBehavioral techniques nPelvic floor electrical stimulation nSurgery nInjection of urethral bulking agents nMeds: muscinic receptor antagonists- Ditropan, Pro-bantine, Detrol Nursing Care: Urinary Incontinence nStress incontinence- Kegal exercises nAssess s/s bladder infection, fecal incontinence, bladder distention nOffer bedpan q2h, usual position to void, privacy, techniques to stimulate urination, bladder training nSelf cath Instrumentation nUrethral catheters nUreteral Catheters nSuprapubic catheters nNephrostomy tubes nIntermittent catheterization Renal & Ureteral Surgery nPost op Care: nFlank incision, side lying position->muscle aches post op nMonitor urine output- 30-50cc/hr nMonitor resp status nMedicate for pain nMonitor for paralytic ileus n n Urinary Diversion nIncontinent urinary diversion nContinent urinary diversion nOrthotopic bladder substitution nPre-op info, assess readiness to learn, involve family, enterostomal nurse nPost-op complications- shock & atelectesis methods of urinary diversion Kock pouch urinary diversion Urinary Diversion nPrevent injury to stoma & good skin care important nMaintain urine output- mucous in urine normal, hi fld intake nSkin problems- alkaline encrustations with dermatitis, yeast infections, product allergies, sheering excoriations nProperly fitting appliance Urinary Diversion nAddress pt’s concerns- body image, offensive odors, sexual, professional & activity concerns nDischarge- teach s/s infection & obstruction, care of ostomy nFitted with appliance 7-10 days post-op & may need to later be refitted nInfo where to buy supplies, emer phone #, ostomy clubs, MD follow up