1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Urinary Tract Infection (Relates to Chapter 46. S. Buckley, RN, MS

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI) Second most common bacterial disease Most common bacterial infection in women

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI) (Cont’d) Accounts for more than 8 million office visits per year >100,000 people hospitalized annually due to UTI

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) >15% patients who develop gram-negative bacteria infection die  33% of these caused by infections originating in urinary tract

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) Bladder and its contents are free of bacteria in majority of healthy patients Minority of healthy individuals have colonizing bacteria in bladder  Called asymptomatic bacteriuria, and does not justify treatment

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) Escherichia coli most common pathogen Counts of 10 5 CFU/ml or more indicate significant UTI (p. 1152, normal count: <10 4 ) Counts as low as 10 2 CFU/ml in a person with signs/symptoms are indicative of UTI

7. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) Fungal and parasitic infections can cause UTIs Patients at risk  Immunosuppressed  Have diabetes  Undergone multiple antibiotic courses  Traveled to certain underdeveloped countries

8. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Web resources; UTI http://video.about.com/womenshea lth/Urinary-Tract-Infection.htmhttp://video.about.com/womenshea lth/Urinary-Tract-Infection.htm basic images http://www.youtube.com/watch?v= u11DfF6fuCMhttp://www.youtube.com/watch?v= u11DfF6fuCM

9. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

10. Classification Upper versus lower  Upper tract Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example Pyelonephritis: Inflammation of renal parenchyma and collecting system

11. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification Upper versus lower (cont’d)  Lower tract Lower urinary tract Usually no systemic manifestations Example Cystitis (inflammation of bladder wall)

12. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Specific terms (to delineate the location of a UTI) Pyelonephritis =inflammation of renal parenchyma and collecting system Cystitis =inflammation of bladder wall Urethritis =inflammation of urethra Urosepsis =uti that has spread into the systemic circulation and is life-threatening

13. Sites of Infectious Processes Fig. 46-1 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

14. Classification (Cont’d) Complicated versus uncomplicated  Uncomplicated Occurs in otherwise normal urinary tract Usually only involves the bladder

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification Complicated versus uncomplicated (cont’d)  Complicated Those with coexisting presence of Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) According to natural history  Initial infection First or isolated Uncomplicated UTI in person who never had one or experiences one remote from a previous UTI (separated by period of years)

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification Natural history (cont’d)  Recurrent Caused by second pathogen in a person who experienced a previous infection that was eradicated If it occurs because original infection was not eradicated, it is classified as unresolved bacteriuria or bacterial persistence

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) Unresolved bacteriuria  Occurs when Bacteria resistant to antibiotic Drug discontinued before bacteriuria is completely eradicated Antibiotic agent fails to achieve adequate concentrations in bloodstream or urine to kill bacteria

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) Bacterial persistence  Occurs when Bacteria develop resistance to antibiotic agent Foreign body in urinary system allows bacteria to survive

20. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Urinary tract above urethra normally sterile Defense mechanisms exist to maintain sterility/prevent UTIs  Complete emptying of bladder  Ureterovesical junction competence

21. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Defense mechanisms (cont’d)  Peristaltic activity  Acidic pH  High urea concentration  Abundant glycoproteins

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Alteration of defense mechanisms increases risk of contracting UTI Predisposing factors  Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder  Foreign bodies Examples: Catheters, calculi, instrumentation

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Predisposing factors (cont’d)  Anatomic factors Examples: Obesity, congenital defects, fistula  Compromising immune response factors Examples: Age, HIV, diabetes

24. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Predisposing factors (cont’d)  Functional disorders Example: Constipation  Other factors Examples: Pregnancy, multiple sex partners (women)

25. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Menopause factor in incidence of UTI  Postmenopausal women have lower estrogen levels, ↓ in vaginal lactobacilli, ↑ in vaginal pH Overgrowth of other organisms results  Low-dose intravaginal estrogen replacement may be effective in treating recurrent UTIs

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Organisms introduced via the ascending route from the urethra and originate in the perineum Less common routes  Bloodstream  Lymphatic system

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Gram-negative bacilli normally found in GI tract common cause Urologic instrumentation allows bacteria to enter urethra and bladder

28. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Contributing factor: Urologic instrumentation  Allows bacteria present in opening of urethra to enter urethra or bladder Sexual intercourse promotes “milking” of bacteria from perineum and vagina  May cause minor urethral trauma

29. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Rarely result from hematogenous route For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract  Obstruction of ureter  Damage from stones  Renal scars

30. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Hospital-acquired UTI accounts for 31% of all nosocomial infections  Causes Often: E. coli Seldom: Pseudomonas  Catheter-acquired UTIs Bacteria biofilms develop on inner surface of catheter

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (lower urinary tract) Symptoms related to either bladder storage or bladder emptying  Bladder storage Urinary frequency Abnormally frequent (> every 2 hours) Urgency Sudden strong desire to void immediately Incontinence Loss or leakage or urine

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations  Bladder storage (cont’d) Nocturia Waking up ≥2 times at night to void Nocturnal enuresis Complaint of loss of urine during sleep  Bladder emptying Weak stream Hesitancy Difficulty starting the urine stream

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations  Bladder emptying (cont’d) Intermittency Interruption of urinary stream while voiding Postvoid dribbling Urine loss after completion of voiding Urinary retention Inability to empty urine from bladder

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations  Bladder emptying (cont’d) Dysuria Difficulty voiding Pain on urination

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Urine may contain visible blood or sediment (hematuria ), giving cloudy appearance (Flank pain, chills, and fever indicate infection of upper tract  Pyelonephritis)

36. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) In older adults  Symptoms often absent  Experience nonlocalized abdominal discomfort rather than dysuria  May have cognitive impairment  Less likely to have a fever

37. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Patients with significant bacteriuria  May have no symptoms  Nonspecific symptoms such as fatigue or anorexia

38. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies History and physical examination Dipstick urinalysis  Identify presence of nitrates, WBCs, and leukocyte esterase

39. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

40. Diagnostic Studies (Cont’d) Urine for culture and sensitivity (if indicated)  Clean-catch sample preferred  Specimen by catheterization or suprapubic needle aspiration more accurate  Determine bacteria susceptibility to antibiotics

41. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Imaging studies  IVP or abdominal CT when obstruction suspected

42. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

43. Collaborative Care Drug Therapy Antibiotics  Selected on empiric therapy or results of sensitivity testing  Uncomplicated cystitis Short-term course (1 to 3 days)  Complicated UTIs Requires long-term treatment (7 to 14 days)

44. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy Antibiotics (cont’d)  Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial Inexpensive Taken BID E. coli resistance to TMP-SMX ↑

45. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy Antibiotics (cont’d)  Nitrofurantoin (Macrodantin) Given three or four times a day Long-term use Pulmonary fibrosis Neuropathies  Fluoroquinolones Treat complicated UTIs Example: Ciprofloxacin (Cipro)

46. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) Urinary analgesic  Pyridium Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange Can be mistaken for blood and may stain underclothing OTC

47. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy Urinary analgesic (cont’d)  Urised Used in combination with antibiotics Used to relieve UTI symptoms Preparations with methylene blue tint urine blue or green

48. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs

49. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) Suppressive therapy often effective on short-term basis  Limited because of antibiotic resistance ultimately leading to breakthrough infections

50. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment Health history  Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer  Antibiotics, anticholinergics, antispasmodics  Urologic instrumentation  Urinary hygiene

51. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment Health history (cont’d)  N/V, anorexia, chills, nocturia, frequency, urgency  Suprapubic/lower back pain, bladder spasms, dysuria, burning on urination

52. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment (Cont’d) Objective Data  Fever  Hematuria, foul-smelling urine, tender, enlarged kidney  Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP

53. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses Impaired urinary elimination Ineffective therapeutic regimen management

54. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning Patient will have  Relief from lower urinary tract symptoms  Prevention of upper urinary tract involvement  Prevention of recurrence

55. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health Promotion  Recognize individuals at risk Debilitated persons Older adults Underlying diseases (HIV, diabetes) Taking immunosuppressive drug or corticosteroids

56. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health Promotion (cont’d)  Emptying bladder regularly and completely  Evacuating bowel regularly  Wiping perineal area front to back  Drinking adequate fluids (15 ml/lb) 20% fluid comes from food

57. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. cystitis

58. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health Promotion (cont’d)  Cranberry juice or cranberry essence may help decrease risk  Avoid unnecessary catheterization and early removal of indwelling catheters  Aseptic technique must be followed during instrumentation procedures

59. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Web resources http://www.livestrong.com/video/17 94-urinary-tract-infection-health- byte/http://www.livestrong.com/video/17 94-urinary-tract-infection-health- byte/

60. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health Promotion (cont’d)  Wash hands before and after contact  Wear gloves for care of urinary system  Routine and thorough perineal care for all hospitalized patients  Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals

61. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Acute Intervention  Adequate fluid intake Patient may think will worsen condition due to discomfort Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize

62. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Acute Intervention (cont’d)  Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods Potential bladder irritants

63. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Acute Intervention (cont’d)  Application of local heat to suprapubic or lower back may relieve discomfort  Instruct patient about drug therapy and side effects

64. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Acute Intervention (cont’d)  Emphasize taking full course despite disappearance of symptoms  Second or reduced drug may be ordered after initial course in susceptible patients

65. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Acute Intervention (cont’d)  Instruct patient to watch urine for changes in color and consistency and decrease in cessation of symptoms  Counsel that persistence of lower tract symptoms beyond treatment, onset of flank pain, or fever should be reported immediately

66. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Ambulatory and Home Care  Emphasize compliance with drug regimen Take as ordered  Maintain adequate fluids  Regular voiding (every 3 to 4 hours)  Void after intercourse

67. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Ambulatory and Home Care (cont’d)  Temporarily discontinue use of diaphragm  Instruct on follow-up care  Recurrent symptoms typically occur 1 to 2 weeks after therapy

68. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids

69. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Pyelonephritis

70. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. pyelonephritis http://ehealthforum.com/videos/2211/kidney-infection- pyelonephritishttp://ehealthforum.com/videos/2211/kidney-infection- pyelonephritis

71. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Inflammation of renal parenchyma and collecting system (infection of kidneys and ureters) Caused most commonly by bacteria Fungi, protozoa, or viruses infecting kidneys can also cause

72. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

73. Etiology and Pathophysiology (Cont’d) Urosepsis  Systemic infection from urologic source  Prompt diagnosis/treatment critical Can lead to septic shock and death Septic shock: Outcome of unresolved bacteremia involving gram-negative organism

74. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Usually begins with colonization and infection of lower tract via ascending urethral route Frequent causes  Escherichia coli  Proteus  Klebsiella  Enterobacter

75. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Preexisting factor usually present  Vesicoureteral reflux Backward movement of urine from lower to upper urinary tract  Dysfunction of lower urinary tract Obstruction from BPH Stricture Urinary stone

76. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) Commonly starts in renal medulla and spreads to adjacent cortex Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis

77. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) One of most important risk factors  Pregnancy-induced physiologic changes in urinary system

78. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Mild fatigue Chills Fever Vomiting Malaise

79. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Flank pain Lower urinary tract symptoms characteristic of cystitis Costovertebral tenderness usually present on affected side Manifestations usually subside in a few days, even without therapy  Bacteriuria and pyuria still persist

80. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies History Physical examination  Palpation for CVA pain Laboratory tests  Urinalysis  Urine for culture and sensitivity  CBC with differential  Blood culture (if bacteremia is suspected)

81. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Ultrasound CT scan

82. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria WBC casts indicate involvement of renal parenchyma CBC will show leukocytosis with increase in immature bands

83. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Imaging studies (IVP or CT) requiring intravenous injection of contrast metals  Usually not obtained in early stages to prevent possible spread of infection Ultrasonography of urinary system to identify anatomic abnormalities or presence of obstructing stone

84. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Imaging studies also used to assess complications of pyelonephritis  Impaired renal function  Scarring  Chronic pyelonephritis  Abscesses

85. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) If bacteremia is a possibility, close observation and vitals monitoring are essential Prompt recognition and treatment of septic shock may prevent irreversible damage or death

86. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Hospitalization for patients with severe infections and complications  Such as nausea and vomiting with dehydration Signs/symptoms typically improve within 48 to 72 hours after starting therapy

87. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug therapy  Antibiotics Parenteral in hospital to rapidly establish high drug levels  NSAIDs or antipyretic drugs Fever Discomfort  Urinary analgesics

88. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Relapses may be treated with 6- week course of antibiotics Follow-up urine culture and imaging studies

89. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Reinfections treated as individual episodes or managed with long-term therapy  Prophylaxis may be used for recurrent infection

90. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment Health history  Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer  Antibiotics, anticholinergics, antispasmodics  Urologic instrumentation  Urinary hygiene

91. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment Health history (cont’d)  Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency  Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination

92. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment (Cont’d) Objective Data  Fever  Hematuria, foul-smelling urine, tender, enlarged kidney  Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP

93. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses Acute pain Impaired urinary elimination

94. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning Patient will have  Relief of pain  Normal body temperature  No complications  Normal renal function  No recurrence of symptoms

95. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health Promotion  Early treatment for cystitis to prevent ascending infections Patient with structural abnormalities is at high risk Stress for regular medical care

96. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Ambulatory and Home Care  Need to continue drugs as prescribed  Need for follow-up urine culture  Identification of risk for recurrence or relapse  Encourage adequate fluids

97. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Ambulatory and Home Care (cont’d)  Rest to increase comfort  Low-dose, long-term antibiotics to prevent relapses or reinfections  Explain rationale to enhance compliance

98. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids

99. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study

100. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study 27-year-old female with urgency to urinate, frequent urination, and urethral burning during urination Symptoms began 48 hours ago

101. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Urine has strong odor and cloudy appearance History of recurring urinary tract infections since 22 years of age when she got married

102. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Allergic to penicillin Temperature 98.6° F orally Blood pressure 114/64 mm Hg

103. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Urinalysis results  Color: dark yellow  pH: 6.5  Nitrates: positive  Leukocytes: large amount  Trace occult blood  Urine culture: E. coli >10 6 CFU/ml Sensitivity to ampicillin, nitrofurantoin, ciprofloxacin, cephalexin, TMP-SMX

104. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1.What type of urinary tract infection does she probably have? 2.Why might she be having recurring infections?

105. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions (Cont’d) 3.What is the priority of care for her? 4.What teaching should be done with her?