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URINARY TRACT INFECTION

●Most common cause is Escherichia Coli.

●More common in woman.

CLASSIFICATION:

●Pyelonephritis. ●Urethritis. ●Cystitis.

DIAGNOSTIC STUDY:

●Initially dipstick urinalysis.

●Urine culture and sensitivity.

NURSING ASSESSMENT

SUBJECTIVE:

●Important health information:

1. Past medical history: Previous UTI, urinary calculi, pregnancy, BPH, STD, bladder cancer.

2. Medications: Use of antibiotics, anticholinergics, antispasmodics.

3. Surgery or other treatments: Recent urological instrumentation (catheterization, cystoscopy, surgery).

●Symptoms:

1. N/V, anorexia and chills.

2. Lassitude, malaise.

3. Urinary frequency, urgency, hesitancy

4. Suprapubic or low back pain, dysuria, burning on urination, sense of incomplete emptying.

OBJECTIVE:

1.  Fever.

2. Cloudy and foul smelling urine.

●Possible laboratory findings:

1. Leukocytosis.

2. Pyuria.

3. Positive presence of bacteria in urinalysis and positive urine culture.

Collaborative care and drug therapy:

●Antibiotics may be selected by the MD or based on the sensitivity testing.

●Uncomplicated cystitis can be treated with short term course of antibiotics 1-3 days.

●Complicated UTI 7-14 days.

Drugs: Trimethoprim-sulfamethoxazole, Nitrofurantoin, Macrobid.

Ampicillin or amoxicillin – uncomplicated UTI 3-4x daily.

Phenazopyridine (Pyridium): for pain – urine color will be reddish orange is normal.

HEALTH PROMOTION: Teachings and interventions

  • Emptying the bladder regularly and completely.

  • Evacuating the bowel regularly (avoid constipation).

  • Wiping the perineal area from front to back after urination and defecation.

  • Drinking adequate amount of liquid each day. (33ml/kg) anyway at least 3000 mL

  • Drink pure cranberry juice or take cranberry essence tablet. (Acid Ash Diet).

  • Seek immediate treatment once symptoms are identified.

  • Other patient or family teaching:

  • Explain the importance of taking all antibiotics as prescribed.

  • Empty the bladder before and after intercourse.

  • Explain not to use harsh soaps, bubble baths, powders, and sprays in the perineal area.

  • Avoid irritants (caffeine, alcohol, chocolate, and highly spiced).

Nurse role: ●Avoid unnecessary catheterization or early removal of indwelling catheter - aseptic technique must always be followed. ●Washing hands before and after contact with patients. ●Wearing of gloves for care involving the urinary system. ●Routine and thorough perineal hygiene especially after bedpan used. ●Answering the call light immediately to offer bedpan or urinal for bedridden patients.

RENAL CALCULI

Presence of stone in the urinary tract.

●More common in men (50 and above – d/t hypertrophy of the prostate, increasing residual urine volume or stasis and predisposing precipitation of organic crystals).

TYPES OF STONE:

●Calcium (phosphate and oxalate) most common (hypercalcemia or hyperparathyroidism). ●Uric acid. ●Cystine. ●Struvite.

       RISK FACTORS:

  • Metabolic: Abnormalities that increased urine levels of calcium, oxaluric acid, uric acid, or citric acid.

  • Climate: Warm climates that cause increased fluid loss, low urine volume, and increased solute concentration in urine.

  • Diet: High purine, calcium, oxalates, phosphates in the diet, low fluid intake.

  • Genetic and PMH: Family history renal calculi and gout. Previous UTI, BPH, kidney disease with urinary stasis.

  • Lifestyle: Sedentary, immobility.

  • Surgery and treatments: Long-term indwelling urinary catheter and external urinary diversion.

  • SIGNS AND SYMPTOMS:

  • Nausea and vomiting, chills, and fever.

  • Decrease urine output, urinary urgency, frequency, and feeling of bladder fullness.

  • Flank, back, abdomen or groin pain.

  • Burning on urination, dysuria.

  • Guarding.

  • Hematuria, passage of stone (strain urine).

  • Abdominal distension.

MANAGEMENT:

  • Increase fluid intake – 3-4 L per day if not contraindicated (especially at night).

  • Encourage activity.

  • Diet modification (it depends on the kind of stone-see nutritional therapy).

  • Relieve pain (NSAIDS, hot baths, and moist heat to flank area.)

  • Strain urine.

  • Avoid hot weather (DHN prevention).

  • Lithotripsy (ESWL).

  • Open surgical stone removal.

  • NUTRITIONAL THERAPY:

    Avoid:

  • Purine: Sardines, herring, mussels etc…

  • Calcium: milk, yogurt, ice cream etc...

  • Oxalate:  Spinach, rhubarb, asparagus etc…

  • ●Acid ash diet: (Acidify the urine) in calcium stones and struvite stones: Give: meats, eggs, cranberry, plums, prune juice, ascorbic

    ●Alkaline ash diet: (Alkalinize the urine) in uric acid and cystine stone: Give: milk, vegetables and fruits.

  • NURSING INTERVENTIONS:

  • Assess pain (PQRSTU). 

  • Administer analgesics as prescribed.

  • Encourage patient to increase fluid intake, if not contraindicated.

  • Strain urine and assess (COCA).

  • Monitor vital signs (especially temperature)-see management for other interventions.

POSSIBLE LABORATORY FINDINGS:

●Increase BUN and creatinine, RBC, WBC, pyuria, crystals, and minerals. ●Bacteria on urinalysis. ●Increase uric acid, calcium, phosphorus, oxalate, or cystine values in 24 hour urine sample. ●Calculi or anatomical changes on IVP or KUB x-ray study. ●Direct visualization of obstruction on cystouureteroscopy.

CHRONIC RENAL FAILURE

Progressive irreversible deterioration of renal function wherein the body fails to maintain fluid and electrolyte balance resulting to uremia or azotemia.

CLINICAL MANIFESTATION:

  • Electrolyte imbalance.

  • Metabolic change:  Hyperproteinemia, metabolic acidosis.

  • Hematologic: Anemia (↓ erythropoiesis)

  • Gastrointestinal: Anorexia, N/V, ammonia breath, bitter metallic taste.

  • Immunologic: Risk for infection.

  • Cardiovascular: Hypertension, fluid overload.

  • Respiratory: Pulmonary edema.

  • Integumentary: Severe pruritus.

  • Neurologic:  Peripheral neuropathy.

MOST COMMON CAUSE:

1. Diabetes.

2. Chronic pyelonephritis.

3. Glomerulonephritis.

4. Nephropathy.

MANAGEMENT :

  • Kidney transplant.

  • Dialysis (Hemodialysis and peritoneal dialysis).

  • Pharmacologic therapy: Calcium binders and phosphorus, antihypertensive, antiseizure, erythropoietin therapy.

  • Diet: Limit protein, salt, and fluid allowance per day 500-600 mL.

DIALYSIS: Process of removing fluid and uremic waste products from the body when the kidneys are incapable to do so.

COMPLICATIONS:

  • Hypotension: Causes: Taking antihypertensive pills before dialysis, removing too much weight. Treatment: NS bolus, trendelenburg position, use sodium modeling. Prevention: Evaluate target and pre-weight patient, review medication list for BP medications.

  • Muscle cramps: Causes: Associated with removal of large amounts of fluid  (Hypotension). Changes in electrolytes (blood chemistry) • Rapid sodium removal • Low potassium levels.  Inaccurate fluid removal goal. Treatment: NS bolus, massage or apply opposing force.

  • Dialysis disequilibrium syndrome: More common in acute renal failure or when BUN is very high (>150mg/dL) it results from cerebral fluid shifts Signs and symptoms: Headache, N/V, restlessness, decreased level of consciousness and seizures. Treat symptoms per protocol. Prevention: Use smaller dialyzer, shorter dialysis time for new patients.

  • Chills and fever: Causes: Infection or septicemia.  Cold dialysate or malfunctioning thermostat (Patient has shaking/shivering without fever.) Signs and symptoms: Infection (Fever during dialysis, feeling cold with a fever Feeling cold with a fever, redness, swelling, tenderness, warmth or drainage from access site. Septicemia: (Fever, chills, vomiting and headache Fever, chills, vomiting and headache, Hypotensive shock. Respiratory – Produc ve coug tive cough. Treatment: Remove from di a lys is immediately. Gather samples of dialysate/blood per company policy. Prevention: Proper disinfection/sterilization. Use of aseptic technique.

  • Others: Air embolism, clotting, hypertension.

FISTULA CARE: AV-fistula-needs to be mature before it can be used for hemodialysis.

NURSING CARE:

  • Assess for redness, swelling or any pain around the fistula area. Report any sign of fever.

  • Provide mouth care and proper hygiene.

  • Instruct patient to avoid people who have infection.

  • Never take blood pressure or draw blood in the fistula arm.

  • Provide care with aseptic technique.

  • Verify with the pharmacist the possibility of modifying certain medication administration, during the day the patient has hemodialysis treatment. 

MAINTAINING PROPER BLOOD FLOW TO FISTULA:

  • Do not wear tight-fitting shirts.

  • Do not wear jewelry that may restrict blood flow to access arm.

  • When carrying things (groceries, bags, and luggage) make sure the straps or handles does not tighten around the fistula.

  • When sleeping or sitting, make certain that your head pillow or cushion does not rest on your fistula.

CHECKING FISTULA BLOOD FLOW:

By touch: ●Place two fingers over the fistula and feel for “THRILL”-motion of blood flow.

By sound: ●Listen for “BRUIT” sound using bell of stethoscope. If the whooshing sound change to a whistling like sound-stenosis or thrombus.

NURSING INTERVENTIONS/ASSESSMENTS/TEACHINGS: CRF

1. Do a general physical assessment to all system:

●Assess LOC, numbness, muscle cramps, loss of balance or malaise.

●Assess for signs of hypertension, headache, fainting, dyspnea, chest pain.

●Auscultate lungs for any adventitious sounds.

●Assess for edema (peripheral or periorbital).

2. Monitor for signs of hyperkalemia (muscle weakness, arrhythmia, paresthesia, diarrhea, abnormal ECG).

3. Monitor BUN and creatinine.

4. Follow a fluid restriction as ordered.

5. Monitor hemoglobin and hematocrit.

6. Administer medications as ordered (avoid nephrotoxic drugs).

7. Monitor vital signs at least every 4 hours.

8. Monitor intake and output.

9. Weigh patient daily, at the same time of the day.

 10. If patient has itchy skin:

●Evaluate patient skin (color, texture, elasticity and vascularity).

●Assess if any ecchymosis, pruritus, or infection.

●Provide skin care with warm water and unscented bath oil.

●Apply unscented moisturizing cream.

●Cut patient fingernails short and make it clean at all times.

●Monitor calcium and phosphorus.

11. Patient at risk for bone fracture.

●Monitor sign and symptoms of bone pain.

●Encourage range of motion exercises and ambulation.

●Administer vitamin supplements (ex. Calcium and vitamin D).

●Evaluate patient LOC and mental state.

12. Patient at risk for anemia.

●Monitor any sign and symptoms of bleeding.

●Administer iron supplement as ordered and encourage patient to eat foods rich in iron.

●Provide adequate rest for the patient.

●Monitor hematocrit and hemoglobin.

●Provide skin care and assess for any edema.

13. Patient teachings:

●Explain to the patient the risk of possible fracture.

●Teach patient on hypertension prevention.

●Educate about protein restrictions as ordered by their MD.

●Comply with dietary treatment plan.

Nephrotoxic drugs:

●ACE inhibitors. ●ARBS. ●NSAIDS. ●Antibiotics. ●Antacids. ●Chemotherapy drugs or immunosuppressant. ●Radiographic contrast. ●Illicit drugs (cocaine, heroin, methamphetamine, and methadone). ●Aspirin. ●AntiHyperlipidemics.  

CATARACT

A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people.

Risk factors: Diabetes, smoking and alcohol use, prolonged exposure to sunlight, and corticosteroid use.

Other types:

  • Secondary – diabetes, corticosteroids use, glaucoma, and post op eye surgery.

  • Traumatic – eye injury.

  • Congenital – some babies are born with cataract.

  • Radiation – exposure to radiation.

  • DIAGNOSTIC STUDY:

  • Visual acuity test.            

  • Tonometry.

  • Direct observed ophthalmoscope and Slit lamp examination (most accurate).

  • Dilated eye exam.

Symptoms:

  • Cloudy or blurry vision.

  • Colors seem faded.

  • Glare – headlight, lamps or sunlight may appear too bright. A halo may appear around lights.

  • Poor night vision.

  • Double vision or multiple images in one eye.

  • Frequent prescription changes in contact lenses or eyeglasses.

  • MANAGEMENT: Surgical removal

  • Intracapsular or Extracapsular cataract extraction.

  • Phacoemulsitication – use of ultrasonic waves.

Preoperative care: CAMPLES

●Preparation-Prophylactic antibiotic eye drops and mydriatic is given.

Pre-op teachings:

●Operation may last less than one hour.

●Anesthetic is given to numb the nerves in and around the eyes (Anxiolytics may be given).

●A patch will be place after surgery.

●Can go home the same day – do SERA. Don’t allow the patient to drive.

Post-op teachings:

●Explain your monitoring post-operatively.

●Pain medication may be given.

●Explain that the eye may appear swollen after.

●Patient must stay for at least 2 hours until stable.

Post-operative care and discharge:

●Come back to for 1st dressing change - 24h.

●Eye patch (usually removed in the morning).

●Protective shield at night and glasses at day time (protect dust or particles and accidental rubbing of the eye).

●Sleep on unoperative side for at least 3-4 weeks.

●Avoid activities that increase IOP:

1. No bending. 2. Coughing, vomiting. 3. No heavy lifting. 4. No intense activity (house works, sports). 4. Valsalva maneuver – straining at stool.

●No make-up, no ASA. ●Clean eye from inner to outer. ●Explain about the medications h/she takes at home: Teach on how to apply.

1. Predforte (drops). 2. Erythromycine (ointment). 3. Colace + nonpharmacologic constipation prevention. Drops first before ointment – 5mins interval. ●Notify MD if any: ● Bleeding. ●Discharge. ●Decrease vision. ●Fever. ●Swelling. ●Uncontrolled pain.

GLAUCOMA

Increased IOP that can lead to blindness.

TYPES

Acute (closed-angle) –results from obstruction to outflow of aqueous humor.

SURGICAL EMERGENCY

Pain: Severe.

Halos (rainbow around lights).

Blurred vision.

N/V.

Chronic (open-angle) –result from overproduction or obstruction to the outflow of  aqueous humor.

More common – treated with medication

Eyes tire easily.

Tunnel vision (loss of peripheral vision).

Dull H/A common in the morning.

Diagnostic test:●Tonometry >22 mmHg. ●Perimetry. ●Ophthalmoscopy – cupping of the optic disc. ●Snellen’s chart – Poor visual acuityN●Gonioscopy – determines the angle – differentiate open and closed angle.

Note: Never use mydriatics in glaucoma – increase IOP. Avoid activities that increase IOP – (eye pain, n/v).

Surgical management: Laser trabeculoplasty and trabeculotomy.

Medications: Miotics, carbonic anhydrase inhibitor, and beta blockers.

RETINAL DETACHMENT

●A separation of the retina from its attachments to the underlying tissue within the eye.

SIGNS AND SYMPTOMS: ●Flashing lights or floaters (blank areas of vision) – sudden onset.

MANAGEMENT: Surgery -Cryotherapy, Scleral buckling, laser photocoagulation, banding.

BRONCHOSCOPY

What is Bronchoscopy?

A procedure use to visualize the large airways (trachea and bronchi).

Why it is done?

-As diagnostic test (d/t persistent cough and hemoptysis with unknown cause, removal of tissue sample-biopsy).

-Treat various problems (removal of aspiration, open collapse airways using a stent, or to remove tissue growth that blocks the airway).

How it is done?

-Done as outpatient.

-Anesthesia is used.

-Sedative may be given.

-Close monitoring during the procedure (V/S and pulse oximeter).

-O2 NP during procedure.

What preparation needed before bronchoscopy?

-Blood test is done before procedure

-Advise patient not to take medication that affect blood clotting – ASA, warfarin

-NPO + Consent

Post bronchoscopy teachings?

-NPO for 2 hours or until gag reflex return.

-Patient must stay for at least 2 hours until stable.

-No driving, no operating machinery and alcohol drinking + SERA

-Can resume normal activity after 24h

Complication is rare: Coughing up of blood a few times in the following day is normal.

REFERENCES:

 

Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review, The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure

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