MANAGEMENT OF PATIENTS WITH UPPER

OR LOWER URINARY TRACT INFECTIONS

FLUID AND ELECTROLYTE IMBALANCES IN
RENAL DISORDERS
Patients with renal disorders commonly experience fluid and
electrolyte imbalances and require astute assessment and
close monitoring for signs of potential problems.

• Key monitoring tool: The fluid intake and output record -

to document important fluid parameters, including the
amount of fluid taken in (orally or parenterally), the
volume of urine excreted, and other fluid losses (diarrhea,
vomiting, diaphoresis).
CLINICAL MANIFESTATIONS
CLINICAL MANIFESTATIONS
DYSFUNCTIONAL VOIDING PATTERNS
• Urinary incontinence is the unplanned loss of urine that
is sufficient to be considered a problem.
• Continence is maintained via a complex communication
system of suprasacral, sacral, and local nerve-mediated
loops of information, all of which must be functioning
efficiently and synergistically.
CONGENITAL VOIDING PATTERNS
• Adults: lower urinary system is affected (bladder &
urethra)
• Children: upper urinary system is affected (ureters &
kidneys)
• Discovered early in utero because of prenatal care
measures such as ultrasound.
• Depending on the anomaly, intrauterine surgery may
be performed on the fetus.
ADULT VOIDING PATTERNS
URINARY INCONTINENCE
• Urinary incontinence affects people of all ages but is
particularly common among the elderly.
CLINICAL MANIFESTATIONS:
Types of Incontinence
• Stress incontinence- involuntary loss of urine through an intact
urethra as a result of a sudden increase in intra-abdominal
pressure (sneezing, coughing, or changing position).
• Urge incontinence - involuntary loss of urine associated with a
strong urge to void that cannot be suppressed.
• Reflex incontinence - involuntary loss of urine due to
hyperreflexia in the absence of normal sensations usually
associated with voiding.
• Overflow incontinence- involuntary loss of urine associated
with overdistention of the bladder.
Types of Incontinence
• Functional incontinence - instances in which lower
urinary tract function is intact but other factors, such as
severe cognitive impairment (e.g, Alzheimer’s dementia),
make it difficult for the patient to identify the need to
void or physical impairments make it difficult or
impossible for the patient to reach the toilet in time for
voiding.
• Iatrogenic incontinence -involuntary loss of urine due to
extrinsic medical factors, predominantly medications
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Patient’s voiding history
• A diary of fluid intake and output
• Bedside tests (i.e, residual urine, stress maneuvers)
MEDICAL MANAGEMENT
• Treatment of urinary incontinence depends on the underlying cause.
• Behavioral Therapy:
– Fluid Management
– Standardized Voiding Frequency (Timed voiding, Prompted voiding,
Habit retraining, Bladder retraining)
– Pelvic Muscle Exercise (PME)- Kegel exercise
– Vaginal Cone Retention Exercises
– Transvaginal or Transrectal Electrical Stimulation
– Neuromodulation
• Pharmacologic therapy- Anticholinergic agents (oxybutynin [Ditropan],
dicyclomine [Antispas]) inhibit bladder contraction and are considered
first-line medications for urge incontinence
URINARY RETENTION
• Urinary retention is the inability to empty the
bladder completely during attempts to void.
• Urinary retention may result from diabetes, prostatic
enlargement, urethral pathology (infection, tumor,
calculus), trauma (pelvic injuries), pregnancy, or
neurologic disorders such as cerebrovascular
accident, spinal cord injury, multiple sclerosis, or
Parkinson’s disease.
ASSESSMENT AND DIAGNOSTIC FINDINGS
• The patient may verbalize an awareness of bladder
fullness and a sensation of incomplete bladder emptying.
• Assess the patient for signs and symptoms of urinary
tract infection, such as hematuria and dysuria.
• A series of urodynamic studies may be performed to
identify the type of bladder dysfunction and to aid in
determining appropriate treatment.
• The patient may complete a voiding diary to provide a
written record of the amount of urine voided and the
frequency of voiding
COMPLICATIONS
• Urine retention can lead to chronic infection.
• Infections that are unresolved predispose the patient
to calculi, pyelonephritis, and sepsis.
NURSING MANAGEMENT
• Promoting normal urinary elimination
– Encourage voiding include providing privacy, ensuring an
environment and a position conducive to voiding, and
assisting the patient with the use of the bathroom or
commode, rather than a bedpan.
– applying warmth to relax the sphincters (ie, sitz baths,
warm compresses to the perineum, showers), giving the
patient hot tea, and offering encouragement and
reassurance.
– When the patient cannot void, catheterization is used to
prevent overdistention of the bladder
NEUROGENIC BLADDER
• Neurogenic bladder is a dysfunction that results
from a lesion of the nervous system.
• It may be caused by spinal cord injury, spinal tumor,
herniated vertebral disk, multiple sclerosis,
congenital anomalies (spina bifida or
myelomeningocele), infection, or diabetes mellitus.
Two types of neurogenic bladder:
• Spastic (or reflex) bladder- caused by any spinal cord lesion
above the voiding reflex arc (upper motor neuron lesion). The
result is a loss of conscious sensation and cerebral motor
control.
• Flaccid bladder- caused by a lower motor neuron lesion,
commonly resulting from trauma.
– The bladder continues to fill and becomes greatly
distended, and overflow incontinence occurs. The bladder
muscle does not contract forcefully at any time. Because
sensory loss may accompany a flaccid bladder, the patient
feels no discomfort.
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Measurement of fluid intake, urine output, and
residual urine volume; urinalysis;
• Assessment of sensory awareness of bladder fullness
and degree of motor control.
MEDICAL MANAGEMENT
• Preventing overdistention of the bladder
• Emptying the bladder regularly and completely
• Maintaining urine sterility with no stone formation
• Maintaining adequate bladder capacity with no reflux
• Continuous, intermittent, or self-catheterization
• Use of an external condom-type catheter, a diet low in
calcium (to prevent calculi), and encouragement of
mobility and ambulation.
• Pharmacologic therapy- parasympathetic medications,
such as bethanecol increase the contraction of the
detrusor muscle.
• Surgical Management- to correct bladder neck
contractures or vesicoureteral reflux or to perform some
type of urinary diversion procedure.
• Catheterization- When urine cannot be eliminated
naturally and must be drained artificially, catheters may
be inserted directly into the bladder, the ureter, or the
renal pelvis.
DIALYSIS
• Dialysis is used to remove fluid and uremic waste
products from the body when the kidneys cannot do
so.
• It may also be used to treat patients with edema
that does not respond to treatment, hepatic coma,
hyperkalemia, hypercalcemia, hypertension, and
uremia.
HEMODIALYSIS
• Hemodialysis is the most commonly used method of
dialysis.
• A dialyzer (once referred to as an artificial kidney)
serves as a synthetic semipermeable membrane,
replacing the renal glomeruli and tubules as the filter
for the impaired kidneys.
Principles of Hemodialysis
• The objectives of hemodialysis are to extract toxic nitrogenous
substances from the blood and to remove excess water.
• Diffusion, osmosis, and ultrafiltration are the principles on which
hemodialysis is based.
– Diffusion: toxins and wastes in the blood are removed.
– Osmosis: Excess water is removed from the blood
– Ultrafiltration: defined as water moving under high pressure to
an area of lower pressure.
• Accomplished by applying negative pressure or a suctioning
force to the dialysis membrane. Because patients with renal
disease usually cannot excrete water, this force is necessary to
remove fluid to achieve fluid balance.
Principles of Hemodialysis
• The body’s buffer system is maintained using a dialysate
bath made up of bicarbonate (most common) or acetate,
which is metabolized to form bicarbonate.
• The anticoagulant heparin is administered to keep blood
from clotting in the dialysis circuit.
• Cleansed blood is returned to the body.
• By the end of the dialysis treatment, many waste
products have been removed, the electrolyte balance has
been restored to normal, and the buffer system has been
replenished.
VASCULAR ACCESS
• SUBCLAVIAN, INTERNAL, JUGULAR, AND FEMORAL CATHETERS:
Immediate access to the patient’s circulation for acute
hemodialysis is achieved by inserting a double-lumen or
multilumen catheter into the subclavian, internal jugular, or
femoral vein.
• FISTULA: A more permanent access, known as a fistula, is created
surgically (usually in the forearm) by joining (anastomosing) an
artery to a vein, either side to side or end to side
• GRAFT: Arteriovenous graft can be created by subcutaneously
interposing a biologic, semibiologic, or synthetic graft material
between an artery and vein.
Complications of Hemodialysis
• Hypotension
• Painful muscle cramping
• Dysrhythmias
• Air embolism
• Chest pain
• Dialysis disequilibrium
Nutritional and Fluid Therapy
• Restriction of fluid
• Restriction of dietary protein, sodium, potassium,
and fluid intake.
Nursing Management
• MEETING PSYCHOSOCIAL NEEDS
• PROMOTING HOME AND COMMUNITY-BASED CARE:
– Teaching Patients Self-Care
– Teaching Patients About Hemodialysis
CONTINUOUS RENAL REPLACEMENT THERAPIES
• CRRT may be indicated for patients who have acute
or chronic renal failure and who are too clinically
unstable for traditional hemodialysis
• For patients with fluid overload secondary to oliguric
(low urine output) renal failure
• For patients whose kidneys cannot handle their
acutely high metabolic or nutritional needs.
• Continuous arteriovenous hemofiltration (CAVH)- to treat fluid
overload
• Continuous arteriovenous hemodialysis (CAVHD)- offers the
advantage of a concentration gradient for faster clearance of urea.
• Continuous venovenous hemofiltration (CVVH)- provides
continuous slow fluid removal (ultrafiltration); therefore,
hemodynamic effects are mild and better tolerated by patients
with unstable conditions.
• Continuous venovenous hemodialysis (CVVHD)- similar to CVVH.
no arterial access is required, hemodynamic effects are usually
mild, and critical care nurses can set up, initiate, maintain, and
terminate the system.
PERITONEAL DIALYSIS
• The goals of peritoneal dialysis are to remove toxic
substances and metabolic wastes and to re-establish
normal fluid and electrolyte balance.
• Peritoneal dialysis can be performed using several
different approaches: acute, intermittent peritoneal
dialysis; continuous ambulatory peritoneal dialysis
(CAPD); and continuous cyclic peritoneal dialysis
(CCPD).
Complications of Peritoneal Dialysis
• Peritonitis (inflammation of the peritoneum)- is the most
common and most serious complication of peritoneal
dialysis.
• Leakage of dialysate through the catheter site may occur
immediately after the catheter is inserted.
• Bleeding
• Long term complications: Hypertriglyceridemia is
common in patients undergoing long-term peritoneal
dialysis.
Acute Intermittent Peritoneal Dialysis
• Indications for acute intermittent peritoneal dialysis, a
variation of peritoneal dialysis, include uremic signs and
symptoms (nausea, vomiting, fatigue, altered mental
status), fluid overload, acidosis, and hyperkalemia.
Continuous Ambulatory Peritoneal Dialysis
• CAPD works on the same principles as other forms of
peritoneal dialysis: diffusion and osmosis.
Continuous Cyclic Peritoneal Dialysis
• CCPD combines overnight intermittent peritoneal
dialysis with a prolonged dwell time during the day.
• CCPD has a lower infection rate than other forms of
peritoneal dialysis because there are fewer
opportunities for contamination with bag changes
and tubing disconnections.
 NURSING MANAGEMENT
• Protecting the vascular access
• Taking precautions during
intravenous therapy
• Monitoring symptoms of
uremia
• Detecting cardiac and
respiratory complications
• Controlling electrolyte levels
and diet
• Managing discomfort and pain
• Monitoring blood pressure
• Caring for catheter site
• Administering medications
• Providing psychological
support
KIDNEY SURGERY
• A patient may undergo surgery to remove
obstructions that affect the kidney (tumors or
calculi), to insert a tube for draining the kidney
(nephrostomy, ureterostomy), or to remove the
kidney involved in unilateral kidney disease, renal
carcinoma, or kidney transplantation.