1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 69 Care of Patients with Urinary Problems

2. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Learning outcomes 1. Teach the proper application of pelvic floor exercises to reduce or prevent urinary incontinence. 2. Coordinate care to prevent urinary tract infections among hospitalized patients. 3. Compare the pathophysiology and manifestations of stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, and functional incontinence. 4. Differentiate between cystitis and urethritis.

3. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Learning outcomes 5. Describe risk factors contributing to UTI and ways to prevent a UTI. 6. Verbalize the various aspects of bladder training and habit training to reduce urinary incontinence. 7. Implement strategies to minimize catheter related infections. 8. Describe Common examples of drug therapy for UTIs. 9. Teach clients proper self-management techniques for urinary incontinence and renal calculi.

4. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. List of disorders Infectious disorders Cystitis Urethritis Noninfectious disorders Urethral strictures **Urinary incontinence** Urolithiasis https://www.google.com/search?q=urinary+incontinence&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjnotfx- arLAhVlkoMKHU-uCaAQ_AUICCgD#imgrc=24KYdTVmRSIysM%3A

5. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Introduction The urinary system consists of the kidneys, ureters, bladder, and urethra. When problems in the urinary system interfere with the mechanics of moving urine out of the body urinary elimination is inadequate and homeostasis of fluids, electrolytes, nitrogenous wastes, and blood pressure is disrupted.

6. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Introduction Urinary problems affect the storage or elimination of urine. Both acute and chronic urinary problems are common and costly. Nursing interventions are directed toward prevention, detection, and management of urologic disorders.

7. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Infectious disorders UTIs are the most common health care–acquired infection. Urinary tract infections are described by their location in the tract. Acute infections in the urinary tract include urethritis (urethra), cystitis (bladder), and prostatitis (prostate gland). Acute pyelonephritis is a kidney infection. urethritiscystitisprostatitispyelonephritis The site of infection is important to know because site, along with the specific type of bacteria present, determines treatment.

8. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Infectious disorders: Preventing a UTI 3L or more fluids daily Sufficient sleep, rest, nutrition Ladies clean front to back Loose fitting cotton underpants Wash before woopie Call HCP if burning when urinating or increased frequency Pee regularly More on chart 69-2 FYI https://www.google.com/search?q=urinary+system&biw=109 7&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahU KEwithIbkpKjLAhVC6mMKHcjQDOQQ_AUIBigB#tbm=isch&q =grandma+underpants+funny

9. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Infectious disorders: Risk factors contributing to UTI Incomplete bladder emptying Large stones can obstruct urine flow Urine going back from bladder to kidneys and ureters Too much glucose in urine Alkalotic urine Women Advancing age and disease Irritation of perineum and urethra during intercourse Recent use of antibiotics

10. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Infectious disorders: Cystitis and Urethritis https://www.google.com/search?q=glass+of +water&rlz=1C1EODA_enUS644US645&es pv=2&biw=1421&bih=900&tbm=isch&tbo=u &source=univ&sa=X&ved=0ahUKEwjUkoDD 46nLAhVSzGMKHWUJBpkQsAQIGw#tbm=i sch&q=joke+infection+urine&imgrc=rqRDfH oqiHwejM%3A https://s3.amazonaws.c om/lowres.cartoonstock.com/animals-doctor- water_infection- urine_infection- bladder_infection-bear- dren149_low.jpg

11. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Infectious disorders Cystitis is the medical term for inflammation of the bladder. Most of the time, the inflammation is caused by a bacterial infection, and it's called a urinary tract infection (UTI). Urethritis is a condition in which the urethra, or the tube that carries urine from the bladder to outside the body, becomes inflamed and irritated. Urethritis typically causes pain while urinating and an increased urge to urinate. The primary cause of urethritis is usually infection by bacteria. http://www.healthline.com/health/urethritis#Overview1 http://www.mayoclinic.org/search/search-results?q=Urethritis

12. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cystitis Definition and Risk factors Inflammation of bladder Most commonly caused by bacteria moving up urinary tract from external urethra to bladder because of irritation, trauma or catherization (More info on Table 69-2-FYI) Catheters: high risk factor in developing nosocomial cystitis Chart 69-1 https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=urinary+catheter&imgrc=kLFhl5rNkpn4cM%3A

13. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cystitis S+S Frequent urge to urinate Urgency Dysuria Hesitancy or difficulty in initiating urine stream Low back pain Nocturia Incontinence

14. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cystitis Treatment Drugs- Chart 69-4 Nutrition-include all food groups, more calories needed dt increased metabolism because of infection, hydrate Comfort measures- sitz bath Surgery (ie Cystoscopy, remove calculi, remove obstructions)

15. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urethritis Inflammation of urethra causing symptoms similar to UTI Most common in postmenopausal women and appears to be caused by tissue changes related to low estrogen levels. For men, the most common cause is STDs like gonorrhea. https:// www.google.com/search?q=urinary+ system&biw=1097&bih=512&source=lnms&tbm=isc h&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6mM KHcjQDOQQ_AUIBigB#tbm=isch&q=Urethritis&img rc=4lyXsjzOaPEg0M%3A

16. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Noninfectious disorders Urethral strictures Urinary incontinence Urolithiasis https://www.google.com/search?q=urine&biw=1097&bih=512&sour ce=lnms&tbm=isch&sa=X&ved=0ahUKEwjs6sjDqqjLAhVN- GMKHUo- A_kQ_AUIBigB#tbm=isch&q=Non+Infectious+disorders+funny+jok es&imgrc=mX3tDmt1fjNgNM%3A

17. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urethral Strictures Narrowed areas of urethra Most common symptom-obstruction of urine flow Surgical treatment Dilation of urethra (temporary measure) Stent placement Urethroplasty- remove the problem area with option of graft placement https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=Urethral+Strictures+&imgrc=UVUzTaHAb1etjM%3A

18. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Incontinence Pathophysiology Continence is the control over the time and place of urination and is unique to humans and some domestic animals. Continence It is a learned behavior in which a person can suppress the urge to urinate until a socially appropriate location is available (e.g., a toilet).

19. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Incontinence Pathophysiology Incontinence is an involuntary loss of urine severe enough to cause social or hygienic problems. Incontinence It is not a normal consequence of aging or childbirth and often is a stigmatizing and an underreported health problem. Many people suffer in silence, are socially isolated, and may be unaware that treatment is available. In addition, the cost of incontinence can be enormous. https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=money&imgrc=wYYh5M0xUYV91M%3A

20. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Incontinence Pathophysiology Continence occurs when pressure in the urethra is greater than pressure in the bladder. For normal voiding to occur, the urethra must relax and the bladder must contract with enough pressure and duration to empty completely. Voiding should occur in a smooth and coordinated manner under a person's conscious control.

21. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Incontinence Pathophysiology Incontinence has several possible causes and can be either temporary or chronic. Temporary causes usually do not involve a disorder of the urinary tract. The most common forms of adult urinary incontinence are… stress incontinence urge incontinence overflow incontinence mixed incontinence functional incontinence

22. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Types of incontinence (Yes, I know it’s blurry) https://www.google.com/search?q=urinary+incontinence&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjnotfx- arLAhVlkoMKHU-uCaAQ_AUICCgD#imgrc=24KYdTVmRSIysM%3A Too little tone too much activity bothtoo full

23. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Stress Incontinence Occurs during activities that increase abdominal and detrusor (bladder)pressure (exercise, cough, sneeze) Interventions: Drug therapy—estrogen Pelvic floor (Kegel) exercises Ke·gel ex·er·cise an exercise to strengthen the pelvic floor muscles, in which the levator muscles are squeezed and held for five seconds, then released for five seconds, for a number of repetitions. They are used to treat urinary incontinence, or to prepare for or recover from childbirth. https://www.google.com/?gws_rd=ssl#q=kegel+exercises

24. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urge Incontinence Perception of an urgent need to urinate as a result of bladder contractions regardless of volume of urine in the bladder Interventions: Avoid diuretics, nicotine, caffeine and alcohol https://www.google.com/search?q=urinary+system&biw=1097&bih=512&s ource=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6mMK HcjQDOQQ_AUIBigB#tbm=isch&q=urinary+incontinence&imgrc=3_n8SrE A6354zM%3A

25. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. More types of incontinence Overflow Incontinence= Detrusor (bladder) muscles don’t contract and then bladder is over-distended Mixed Incontinence= combo of stress, urge and overflow incontinence Functional incontinence= Leakage of urine caused by factors other than disease of the lower urinary tract. More FYI info in the book

26. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chart 69-9 Best Practice for Patient Safety And Quality Care: Bladder Training and Habit Training to Reduce Urinary Incontinence https://www.youtube.com/watch?v=N3anPVKsVi0 Great 2 minute video on bladder training Bladder training= education program for patients. Client must be alert, aware and able to resist the urge to urinate. Habit training= type of bladder training that is successful in cognitively impaired clients. Chart 69-10 Preparing for Self-Management Urinary Incontinence

27. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Presence of calculi (stones) in urinary tract Calculi often don’t cause symptoms until they pass into the urinary tract. OUCH! https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0 ahUKEwithIbkpKjLAhVC6mMKHcjQDOQQ_AUIBigB#tbm=isch&q=Urolithiasis+&imgrc=GSolhWls-x-v3M%3A https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=Urolithiasis+&imgrc=2Mn5sZfQ2aJuCM%3A

28. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Pathophysiology Urologic stones are caused by many disorders. However, the exact mechanism of stone formation is not entirely understood. Everyone excretes crystals in the urine at some time, but fewer than 10% of people form stones. Most stones contain calcium (calcium oxalate or calcium phosphate) as one part of the stone complex. https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=kidney+stones&imgdii=ztqXT8Kla0fxdM%3A%3BztqXT8Kla0fxdM%3A%3B3RJeOiteIFOJJM%3A&imgrc=z tqXT8Kla0fxdM%3A

29. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Pathophysiology Formation of stones involves three conditions: 1. Slow urine flow, resulting in supersaturation of the urine with the particular element (e.g., calcium) that first becomes crystallized and later becomes the stone 2. Damage to the lining of the urinary tract (e.g., abrasion from crystals) 3. Decreased amounts of inhibitor substances in the urine that would otherwise prevent supersaturation and crystal aggregation https://www.google.com/search?q=urinary+system&biw=1097&bih=512&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwithIbkpKjLAhVC6m MKHcjQDOQQ_AUIBigB#tbm=isch&q=kidney+stones&imgdii=ztqXT8Kla0fxdM%3A%3BztqXT8Kla0fxdM%3A%3B3RJeOiteIFOJJM%3A&imgrc=z tqXT8Kla0fxdM%3A

30. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis: Assessment Personal or family hx? Severe pain (renal colic)? Frequency? Dysuria? Oliguria? Anuria? Bladder distention? Vital signs moderately elevated (dt pain and/or infection)? BP decreased (if severe pain causes shock)?

31. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis: Assessment UA: (Ch 68 review) hematuria common dt stone induced trauma elevated WBC dt urinary stasis bacteria dt urinary stasis increased turbidity dt infection, sediments Blood work Elevated WBC dt infection Elevated minerals (calcium, phosphate, uric acid)

32. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis: Assessment X-rays, IV urograms, CT I spy a stone! IV urography Useful to see where the urinary tract is obstructed I spy a stone! Renal ultrasonography Creates images from sound waves. I spy a stone!

33. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Interventions Manage pain Drug therapy: opioid analgesics (ie: Morphine), NSAIDS (ie: Ketorolac) Complementary and alternative therapy: relaxation, acupuncture, guided imagery Lithotripsy: sound, laser or dry shock waves are used to break up the stone into small fragments. https://www.google.com/search?q=magnifying+glass&rlz =1C1EODA_enUS644US645&espv=2&biw=1421&bih=9 00&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiWzZS i3anLAhVoyYMKHXlKD3MQ_AUIBigB#tbm=isch&q=kidn ey+stones&imgrc=e4CuTLDcDt5qzM%3A

34. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Interventions Surgery Minimally invasive surgical and open surgical procedures are used if urinary obstruction occurs or if the stone is too large to be passed. When other stone removal attempts have failed or when risk for a lasting injury to the ureter or kidney is possible, an open ureterolithotomy (into the ureter), pyelolithotomy (into the kidney pelvis), or nephrolithotomy (into the kidney) procedure may be performed. These procedures are used for a large or impacted stone.

35. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Interventions Prevent infection Antibiotics Adequate nutrition: adequate calories, balanced diet Adequate fluid (3L daily unless contraindicated) Prevent obstruction Adequate fluid (3L daily unless contraindicated) Drugs Walk to help stone(s) to pass more quickly Chart 69-11 Self management

36. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Urolithiasis Why is important to drink 3L or more a day? Why do you want urine in the 1,2 or 3 category? Diluted urine helps to…. prevent dehydration promote the flow of urine decrease the chance of crystals forming a stone.

37. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. A 78-year-old woman is at her annual checkup with her health care provider. She seems very embarrassed about asking if it’s normal to “leak” urine when coughing or laughing, especially at her age. She has given birth to five children. What is the nurse’s best response to this question? A. “Involuntary loss of urine or incontinence is not a normal consequence of childbirth or aging.” B. “As we get older, our bodies do not function as well as when we were younger.” C. “The unintentional loss of urine can be temporary or permanent depending on the cause.” D. “The most likely cause of your urine leakage is obstruction of the urethra with a kidney stone.”

38. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. ANS: A Incontinence is not a normal response to aging or childbirth. It is often stigmatizing and not reported, which results in social isolation and lack of treatment. Responses B and C are true, but do not address the patient’s question. Response D is not true for the type of incontinence this patient may have.

39. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Later in the visit, the patient asks what could have caused her stress incontinence. What is the nurse’s most accurate reply? A. “It could be due to a loss of awareness that urination is about to occur.” B. “It most likely is related to drinking too many caffeinated beverages.” C. “Do you take any diuretics for your blood pressure?” D. “It may be due to weakening of the bladder neck support that is associated with childbirth.” (cont’d)

40. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. ANS: D Stress incontinence is the involuntary loss of urine during activities that increase abdominal and detrusor muscle pressure. It is often caused by weakening of the bladder neck support associated with childbirth. Urine loss occurs with physical exertion such as coughing, sneezing, or exercise.

41. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Before going home, the patient asks what can be done to fix her problem with urine leaking. Which teaching points should the nurse be sure to include? (Select all that apply.) A. First, keep a diary of episodes of incontinence. B. Collection devices can be used during treatment. C. Kegel exercises can help strengthen the muscles that prevent urine leakage. D. You may want to avoid caffeine and other bladder irritants. E. Be sure to drink less than 2 L of fluids every day, especially in the evening. (cont’d)

42. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. ANS: A, B, C, D The patient should consume at least 3 L of fluids per day, especially water.

43. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. The patient says that she vaguely recalls advice from her OB/GYN about Kegel exercises, but does not recall how to perform them. 1. How should the nurse describe this procedure? 2. How many repetitions of this exercise should be recommended that she perform? (cont’d)

44. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 1.(Refer to Chart 69-7: Patient and Family Education—Preparing for Self-Management: Pelvic Muscle Exercises, in textbook, p. 1501.) 2.Do 15 exercises lying down, sitting up, and standing. Begin with 45 exercises a day in 3 sets of 15 exercises each, and repeat this twice a day. Caution the patient that it may take as long as 3 months to notice improvement.

45. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. The patient says that a friend mentioned taking antidepressant drugs when she had a similar problem, and asks if this could help herself. What is the nurse’s best response? A. “Estrogen may be helpful because it can improve vaginal and urethral blood flow.” B. “Tricyclic antidepressants such as imipramine have been helpful in relieving urinary incontinence.” C. “An antispasmodic drug such as oxybutynin would probably be better.” D. “Your problem may be different from your friend’s, requiring a different solution.” (cont’d)

46. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. ANS: B Responses A, C, and D do not address the patient’s question. Response B is accurate, and a good suggestion would be that she discuss this option with her provider.

47. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 1 A 21-year-old male reports burning and difficulty with urination. What priority question would obtain information about the patient’s chief complaint? A. “How long have you had these symptoms?” B. “Do you have low back pain?” C. “Are you sexually active?” D. “Have you had a fever in the past 24 hours?”

48. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: C Rationale: The most common cause of urethritis in men is sexually transmitted diseases (STDs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tracts).

49. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 2 Which patient is at greatest risk of developing a kidney stone? A. African-American female with family history of kidney stones B. Overweight Caucasian male C. Female with history of frequent urinary tract infections D. Hispanic/Latino female who eats animal protein at every meal

50. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: B Rationale: Anyone can form a kidney stone, but you may be more likely to have one if you are male, Caucasian, very overweight, have had kidney infections, have a family member with kidney stones, have had kidney stones before, eat a lot of animal protein (such as meat and eggs), or do not drink enough liquids. (Source: Accessed August 15, 2011, from http://www.kidneyfund.org/kidney-health/kidney-problems/kidney-stones.html)

51. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 3 Once an indwelling urinary catheter is placed, how long before bacterial colonization begins? A. 12 hours B. 24 hours C. 48 hours D. 72 hours

52. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: C Rationale: Catheters are the most common factor that place patients at risk for UTIs in the hospital setting. Within 48 hours of catheter insertion, bacterial colonization begins; thus the goal is to remove the catheter within 48 hours after placement whenever clinically possible. About 50% of patients with indwelling catheters become infected within 1 week of catheter insertion.