NURSING CARE MANAGEMENT 0112 RLE

Ist Semester, Academic Year 2021-2022

MODULE 18 : NURSING CARE MANAGEMENT OF ADULT CLIENTS WITH

URINARY TRACT INFECTIONS AND UROLITHIASIS

MODULE OVERVIEW:
This module is designed and prepared for BSN III students to gain adequate knowledge
on assessment, medical surgical and nursing management of patients with Urinary
Tract Infection and Urolithiasis.

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It is your first duty at Medicine Ward, on one of the tertiary hospitals in Angels City. You are
assigned to patient in ward 3 bed 2. She is a 22 -year-old female, on her day 2 admission. Before
going to the patient, you read her medical records, Miss Kati was admitted due to pain when she
passes urine, with low grade fever, suprapubic and flank pain was also her complain. On your initial
visit to the patient, she told you that she had UTI in the past and felt the same thing. To better
understand what is UTI, you ask you Clinical Instructor about it and group discussion was done.
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URINARY TRACT INFECTION
• a broad term which means infection of any of part of the Urinary System
• caused by pathogenic microorganisms in the urinary tract (the normal urinary tract
is sterile above the urethra)
• generally, classifies as infections involving the upper and lower urinary tract and
further classified as uncomplicated or complicated

CATEGORIES

1. Complicated UTI- results from anatomical defect or inherent factor that

promotes the recurrence of a certain UTI which makes it very hard to treat
and often acquired in the hospital related to catherization.

2. Uncomplicated UTI- refers to the normally occurring UTI which is primarily

caused by the colonic bacteria E. coli

Anatomically UTI may be classified as:

A) Lower UTI - urethritis, cystitis, prostatitis and urethritis

B) Upper UTI - acute and chronic pyelonephritis, renal abscess interstitial

nephritis, perirenal abscess
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After learning on the different classifications of UTI, you went back to check on your patient and
ask her further on her illness history, she verbalized that voiding makes the symptoms worst, she
stated that she increased her fluid intake but did not help relieving the symptoms. She is sexually
active, monogamous relationship. During break time you read more on UTI to better understand
your patients’ case.

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RISK FACTORS:

LOWER UTI:
• Age - Post menopausal and older men
• Females - 1 of 5 experience UTI that may recur
• Sexually active & history of STD
• Dysfunctional voiding patterns
• Poorly fitting diaphragms
• Synthetic underwear and pantyhose, tight jeans, wet bathing suits
• Feminine sprays, perfumed toilet paper, spermicidal gel
• Hospitalization (nosocomial/ instrumentation)
• Immunosuppression
• Certain conditions: neurologic conditions, pregnancy, gout
• Obstructions (Urolithiasis and structural defects)

UPPER UTI
• Reduced host resistance
• Extension of infectious process
• Ureteral reflux
• Same as other risk factors for lower UTI

A. LOWER UTI

CLINICAL MANIFESTATIONS

• ASYMPTOMATIC- 50%
• Dysuria – most common sign of cystitis
• Suprapubic/ pelvic/ flank/ back pain/
• Increased frequency and urgency of urination, voiding in small amounts
• Nocturia
• Incontinence
• Cloudy urine
• Foul-smelling urine
• Hematuria
• Fever and chills
• Body malaise

DIAGNOSTIC PROCEDURES

• Urinalysis- pyuria and hematuria

• Urine cultures- useful in identifying the specific organism present. A colony count
of at least 105 colony forming units (CFU) per mL of urine on a clean-catch
midstream or catheterized specimen in a major criterion for infection.

Other studies
❖ Multiple-test dipstick often include testing for WBCs known as the leukocyte
esterase test, and nitrite testing.
❖ Test for STDs/STIs-may be performed because acute urethritis caused by sexually
transmitted organisms (Chlamydia trachomatis, Neisseria gonorheae, herpes
 simplex) or acute vaginitis infections (Trichomonas or Candida species) may be
responsible for symptoms similar to those of UTIs.
❖ Computed tomography (CT)-may detect abscesses
❖ Ultrasonography-detecting tumors, cysts, abscess and obstruction. Transrectal
ultrasound: choice for men to assess bladder and prostate.
❖ Cystourethroscopy-visualized the ureters or to detect strictures, calculi, or tumors.

MANAGEMENT

• ANTIBIOTICS / URINARY ANTISEPTICS: Sulfonamides (Bactrim),

Fluoroquinolones (ciprofloxacin and nitrofurantoin) and Ampicillin
o 7–10-day treatment
• Phenazopyridine (Pyridium)
• Anticholinergic and Antispasmodic drug- Hyosine ( Buscopan)

NURSING MANAGEMENT

Impaired Urinary Elimination r/t irritation and inflammation of the bladder

mucosa
▪ Inhibit bacterial growth
Modify diet -avoid caffeine, chocolates, alcohol, caffeinated sodas,
spicy food, tomatoes and acidic fruits like lemon, lime and grapefruit
Increase fluid intake

Prevent complications
▪ Teach health promotion activities
✓ Urinating regularly. Try not to “hold it"- every 2 -4 hours during the
day
✓ Pregnant – void q 2 -3 hours
✓ Females: void before and after coitus
✓ Sexually active women – position that will minimize pressure on the
anterior vaginal wall during sex
✓ Maintain good perineal hygiene
✓ Shower rather than tub baths.
✓ avoid bubble baths, salts and scented feminine hygiene products
✓ Wear cotton underwear

Pain r/t irritation and inflammation of bladder and urethral mucosa

• Force fluids
• Application of heat pads on the suprapubic area
• Sitz bath
• Administer urinary analgesics
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Upon learning on the risk factors, clinical manifestations, and management of Lower UTI. On your
post Conference, additional discussions were done by your Clinical instructor.

_____________________________________________________________________

UPPER UTI

PYELONEPHRITIS – inflammation of the renal pelvis and parenchyma (tubule and

interstitial spaces). – caused by bacterial infection. Causes involve either the upward
spread of bacteria from a bladder or spread from systemic sources reaching the kidneys
via the bloodstream.

TYPES
1. Acute Pyelonephritis
• Bacterial contamination of the urethra or streptococcal infection from
bloodstream.
• Enlarged kidneys, eventual atrophy, destruction of glomeruli and
tubules
2. Chronic Pyelonephritis
• Recurrent attacks or due to chronic obstruction

CLINICAL MANIFESTATIONS
ACUTE:
o Enlarged kidneys
o High fever & chills
o Colicky pain
o Tenderness on the costovertebral angle
o Signs and symptoms of cystitis
o UA (cloudy, bloody, foul smelling, marked increase in WBC)
o Nausea and vomiting

CHRONIC:
o Usually no s/sx until acute exacerbation occurs
o Polyuria, polydipsia, fatigue, backache, weight loss, poor appetite
o Hypertension is the most frequent manifestation of the disease
o Acidosis, azotemia, pyuria and proteinuria.

DIAGNOSTIC PROCEDURES

ACUTE:
• Ultrasound study and CT scan to locate any obstruction in the urinary tract.
Relief of obstruction is essential to prevent the complications and eventual
kidney damage.
• Intravenous pyelogram-use of radionuclide imaging with gallium citrate and
indium-111 to identify sites of infection not visualized with UTZ or CT.
• Urine culture and sensitivity to identify appropriate antimicrobial agents to
prescribe.

CHRONIC:
• Intravenous pyelogram/urogram (IVP/IVU)- measurements of creatinine
clearance, BUN, and creatinine levels

MANAGEMENT

ACUTE:
o Broad spectrum antibiotics
o First line therapy (Sulfonamides, Sulfamethoxazole and
trimetroprim) x 10 days to 2 weeks.
o Management of pain

CHRONIC:
o Antibiotics
o Management of hypertension
o Reduce dietary sodium
o Antihypertensive drugs
COMPLICATIONS
End-stage renal disease from progressing loss of nephrons secondary to chronic
inflammation and scarring, hypertension, and formation of kidney stones from chronic
infection with urea-splitting organisms.

NURSING MANAGEMENT
Risk for fluid volume deficit r/t nausea, vomiting and fever
OUTCOME: The client will maintain fluid balance AEB balanced I&O, maintenance
of adequate hydration and absence of S & Sx of DHN.
• Prepare the client for diagnostic tests and antibiotic therapy
• Administer IVF as ordered

Pain r/t inflammatory process in the kidney and possible colic

• Pain assessment
• Increase OFI to 3-4L/day
• Analgesics
• Antibiotics to control infection
• Adequate treatment quickly reverses dysuria, pyuria and frequency
• Antipyretic and antiemetic
• Readiness for enhanced therapeutic regimen management to prevent
recurrent infections

After learning all about Urinary tract Infection, it is important to know and learn how to instruct
patient who will do Urine test or Urinalysis. Skill Checklist on how to collect urine sample is further
discuss by your Clinical Instructor. As part of your assessment activity for the week, you are task to
do a return demonstration/ Video recording on urine collection. The following video link are given
by your instructor, to guide you in your recording.
Videos on how to properly collect urine samples
https://bit.ly/3hxGJly
https://bit.ly/3eVsq8U
https://bit.ly/3hHcjxh

______________________________________________________________________

On your day 2 Clinical duty on the same tertiary hospital, as your group pass by the emergency
room, you saw a patient entered the emergency Room in severe pain and immediately had bouts
of vomiting. You wonder what happened to the patient. After your pre-conference and brief review
on UTI, your Clinical instructor assigned you to patient in room 214. Before your visit to the patient,
you went through his medical records. Patient is 32 years old male, married. Initial VS BP. 130/80.
PR-90bpm, RR-28bpm T- 37.8 C. Patient was admitted due to severe left flank pain accompanied
by vomiting with low grade fever and dysuria. Admitting diagnosis Urolithiasis. To prepare you in
your assessment of the patient, you ask your Clinical Instructor what Urolithiasis is .
____________________________________________________________________________

UROLITHIASIS
• Formation of insoluble stones/calcifications in the urinary system.
• Nephrolithiasis, ureterolithiasis and cystolithiasis

General Risk Factors:

• Immobility and sedentary lifestyle
• Dehydration
• Metabolic disturbances
• History of urinary calculi
 • High mineral content in drinking water
• Diet high in purines, oxalates, calcium supplements, animal proteins
• Recurrent or Chronic UTI
• Prolonged indwelling catheterization
• Neurogenic bladder
• Massive doses of vitamin C

Clinical Manifestations:
• Pain – sharp, severe of sudden onset/ intermittent
• Nausea, vomiting, pallor, grunting respirations
• Elevated BP and pulse, diaphoresis and anxiety
• Obstruction of urine flow
• Infection and UTI
• Pyuria
• Hematuria, increased frequency & urgency of urination
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Learning what urolithiasis is, its risk factors and clinical manifestations, you’ve went thru the
doctor’s order, the patient is due for series of Diagnostic procedure. You confidently visit your
patient for your history taking and VS monitoring. Surprisingly, the patient you saw in the ER is your
patient. As you enter the room, patient was relieved from pain and you were able to talk to him,
patient had history of renal calculi 5 years ago and has undergone Lithotripsy.

Diagnostics:
• X-rays of the kidneys, ureters and bladder (KUB)
• Ultrasonography
• IV urography
• Retrograde pyelography
• Blood chemistry and 24-hour urine test for measurement of calcium, uric acid,
creatinine, sodium, pH, and total volume.
• Stone analysis-done to detect disorders (calcium oxalate or urate stones)

Four main Chemical type

Type Risk Factors Management

Calcium
(Phosphate or oxalate)
Accounts for 75%
Struvite stores
(magnesium ammonia
phosphate) (15-20%)
Uric acid (5-10%)
• Hypercalciuria • Phosphates &
• Hypercalcemia calcium binding
• Hyperparathyroidism agents
• Immobility & bone disease
• Vitamin D intoxication • Diet: Acid ash diet,
• Prolonged steroid intake, Limit food high in
• Alkaline urine oxalate
• Dehydration • Low CHON diet
• Inflammation & bowel • Increase hydration
diseased • Exercise
• High CHON diet
• Overdosage of ascorbic
acid
• UTIs especially Proteus • Antibiotic therapy
infections for UTI
• Alkaline urine • Diet: acid ash diet
• Gout • Allopurinol
• Diet high in purine • Diet: Alkaline ash
diet

Cystine (uncommon) 2%
• High concentrations of uric Low-purine diet
acid in the urine • Increase hydration
• Acidic urine
• 25% are patients with
Gout
• Genetic defect • Penicillamine
• Cystinuria • Diet: Alkaline ash
diet
Low protein diet
• Increase hydration

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You accompanied your patient in the X-ray department for his ultrasound and KUB, you read
about the diagnostic procedure and further discuss by Clinical Instructor, you want to know what
are the Medical, Surgical management and what will be your nursing responsibilities in caring for
patient with Urolithiasis.
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Medical Management:
Aims: (1) to halt the formation of stones but cannot resolve the condition if the stone
composition is dense
(2) to stabilize the patient, resolve infection before referring for surgical
consultation.

Surgical Management:
• Endourologic procedures
• Ureteroscopy.
• Nephoscopy
• Lithotripsy
• Cystolitholapaxy/cystoscopic lithotripsy
o Complications: Hemorrhage, urinary retention, infection, bladder perforation
and retained stone fragments

• Laser Lithotripsy
o Constant water irrigation of ureter is required to dissipate heat
o Extracorporeal Shock Wave Lithotripsy (ESWL)
o conscious sedation or general anesthesia
o Fragmented stones are retrieved endoscopically
o Procedure lasts 30-50 minutes with administration of 500-1500
shock waves
o Cardiac monitoring is required to synchronize shock waves with R
wave Complications: Ecchymosis on affected flank, retained
fragments, urosepsis, perinephric hematoma and hemorrhage
o Post Procedural Interventions
o Antispasmodics
o Encourage early ambulation and increase OFI
o Fragments may be passed for up to 3 months after the procedure

• Percutaneous Lithotripsy

• Open surgical procedures

• Ureterolithotomy
• Cystolithotomy
• Pyelolithotomy
• Nephrolithotomy
• Partial or total nephrectomy – rare
Nursing Management:
Possible Nursing Diagnoses:
• Acute Pain r/t irritation and spasm from stone movement in the urinary tract
• Effective therapeutic regimen management r/t prevention of recurrent calculi
• Risk for injury r/t postoperative complications
o Increase fluids
o Monitor urine output
o Prevent complications
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Before duty ends, your clinical instructor provided you a video link to learn more about urolithiasis
and ESWL.
Video viewing to better understand Urolithiasis
https://www.youtube.com/watch?v=hoT2U0ar7Mc

Video viewing on ESWL (Extracorporeal Shock Wave Lithotripsy)

https://www.youtube.com/watch?v=fR_CjlVXhzw

Additional assessment for this activity, you are task to search an Evidence based Journal. This is
an individual activity; you are task to search and critically analyze journal on current trends on
Urolithiasis Management using EBSCO host and Science Direct. To be submitted on 3rd RLE day
not later than 7AM

Asynchronous Activity
To evaluate your learnings on UTI and Urolithiasis, a 30 items multiple choice type of
summative quiz will be given.
You are given the rest of the day to finish your Video recording on skills Checklist 6.1 and 6.3.
submission due 3RD RLE day not later than 5pm.

C O N G R AT U L A T I O NS AND
BEST OF LUCK ON YOUR FINAL
EXAMS.

REFERENCES
• Brunner & Suddarth’s Textbook on Medical-Surgical Nursing. Smeltzer, S.C. et al.
• Brunner & Suddhart’s Textbook of Medical-Surgical Nursing 13th edition. Hinkle,J and
Cheever,K..
Contributor: Ma. Teresa S. Cabanayan, RN, MN
NCM 0112 RLE Instructor

Peer Reviewed by: Gail Marie B. Gozun,RN,RM,NCII,MSN

NCM 0112 RLE Instructor

Prepared by:

Evangeline C. Bautista, RN, MAN

Reviewed and Evaluated by:

Anna Lyn M. Paano, RN, MAN
Level III Academic Coordinator

Sherwin M Quizon, RN, MN

Level III RLE Coordinator

Debbie Q. Ramirez, RN, PhD

Assistant Dean

Approved by:

Zenaida S. Fernandez, RN, PhD

Dean