UNIT NINE
696
Understanding the Urinary System
Risk Factors for Urinary Tract Infections • Aging increases the incidence of UTIs due to diminished immune function, diabetes, estrogen decline in women, enlarged prostate that obstructs urine flow in men, or a neurogenic bladder that fails to completely empty. UTI is the most common cause of acute bacterial sepsis in patients older than 65. • Contamination in the perineal and urethral areas , which can ascend the urinary tract, may occur from genital piercing; fecal soiling; sexual intercourse that massages bacteria into the urinary meatus; or infections such as vaginitis, epididymitis, or prostatitis. • Faulty valves causing reflux of urine do not maintain one-way urine flow along the urinary tract. Reflux can be congenital or acquired because of previous infections. • Female anatomic and genetic differences make women more susceptible to UTIs because of the short length of the female urethra and its proximity to the vagina and anus. Some women with recurrent UTIs have a shorter distance from the urethra to anus. Genetic factors may play a role in women who have a certain phenotype for developing UTIs. • Instrumentation infection occurs from instruments or tubes inserted into the urinary meatus. The most common cause of instrumentation infection is insertion of a urinary catheter. Bacteria ascend around or within the catheter. Bacterial colonization begins within 48 hours of indwelling catheter insertion. • Previous UTIs might provide a reservoir of bacteria that can cause reinfection. • Stasis of urine in the bladder results from voiding infrequently or obstruction. Urine stasis promotes bacterial growth, which can ascend to higher structures. NURSING CARE TIP When caring for a patient at risk for an internal catheter- associated urinary tract infection (CAUTI), limit the use of a urinary catheter, always use infection control procedures, and discontinue use as soon as possible. CAUTI is a Never Event—that is, hospitals will not be paid by Medicare for the costs of care provided if this condition occurs during hospitalization. An external female catheter, the Purewick (www.pure wickathome.com), keeps females who are incontinent dry without being invasive. This reduces the risk of CAUTI. The Purewick is an external sponge/suction catheter that is placed between the labia and the gluteus muscles. It is attached to a suction device at the lowest setting to absorb and wick away the urine. Signs and Symptoms UTIs are characterized by shared signs and symptoms along with location-specific symptoms (Table 37.1). Decline in mental status and fever in a patient with an indwelling
Table 37.1 Urinary Tract Infection (Urethritis, Cystitis, Pyelonephritis) Summary
Signs and Symptoms
All: Voiding urgency, frequency, and burning; cloudy, foul-smelling urine; hematuria Older adult: Fatigue, confusion, and delirium Cystitis: Pelvic pain or pressure Pyelonephritis: Costovertebral tenderness, high fever, chills, nausea/vomiting Urinalysis: White blood cells, red blood cells, casts, bacteria, positive for nitrites Urine culture: Positive Antimicrobial for causative organism Encourage fluids Phenazopyridine (Pyridium)
Diagnostic Tests
Therapeutic Measures
Complications
Pyelonephritis Urosepsis
Priority Nursing Diagnoses
Acute Pain Impaired Urinary Elimination Ineffective Health Maintenance Behaviors
catheter meets diagnostic criteria for a UTI. In older adults, the typical presenting symptom is generalized fatigue. New- onset confusion or delirium may be present in the older adult, but a fever may not be. Types of Urinary Tract Infections Urethritis Urethritis is inflammation of the urethra caused by a chem- ical irritant, bacterial infection, trauma, or exposure to a sexually transmitted infection (STI). Posttraumatic urethritis can occur with intermittent catheterization or instrumenta- tion of the urethra. Bubble bath, bath salts, and spermicidal agents are urethral irritants and should be avoided by anyone with a history of UTI. Gonorrhea and chlamydia are STIs that can cause urethritis in men. Signs and symptoms of urethritis are listed in Table 37.1. The male patient may have discharge from the penis. Urinalysis and urine culture are used to diagnose urethritis. It is treated on the basis of the cause. In cases of sexual transmission, the sexual partner(s) must also be treated. Phenazopyridine (Pyridium),
• WORD • BUILDING • urethritis: urethr—urethra (canal that discharges urine from bladder) + itis—inflammation
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