708 UNIT VII / Responses to Altered Urinary Elimination antibiotics and urinary anti-infectives is commonly used. In Nursing implications for these diagnostic procedures are some cases, surgery may be indicated to correct contributing presented on p. 000. factors. Diagnostic Tests Nursing Implications Laboratory testing for UTI includes: for Diagnostic Tests • Urinalysis to assess for pyuria, bacteria, and blood cells in The Client with UTI the urine. A bacteria count greater than 100,000 (105) per INTRAVENOUS PYELOGRAPHY (IVP) milliliter is indicative of infection. Rapid tests for bacteria in Preparation the urine include using a nitrite dipstick (which turns pink in •Assess knowledge and understanding of procedure, clarify- the presence of bacteria) and the leukocyte esterase test, an ing information as needed. indirect method of detecting bacteria by identifying lysed or •Schedule IVP prior to any ordered barium test or gallbladder intact white blood cells (WBCs) in the urine. studies using contrast material. Urine should be a midstream clean-catch specimen; if •Ask about allergy to seafood, iodine, or radiologic contrast necessary, straight catheterization or “mini-cath,” with strict dye. Notify physician or radiologist if allergies are known. aseptic technique may be used. Catheterization is avoided if •Verify the presence of a signed consent for the procedure. •Assess renal and fluid status, including serum osmolality, possible to reduce the risk of further infection. creatinine, and blood urea nitrogen (BUN) levels. Notify the • Gram stain of the urine may be done to identify the infect- physician of any abnormal values. ing organism by shape and characteristic (Gram positive or •Instruct the client to complete ordered pretest bowel prepa- negative). ration, including prescribed laxative or cathartic (see p. 000) • Urine culture and sensitivity tests may be ordered to identify the evening before the test, and an enema or suppository the infecting organism and the most effective antibiotic. the morning of the test. Withhold food for 8 hours prior to Culture requires 24 to 72 hours, so treatment to eliminate the the test; clear liquids are allowed. most common organisms often is initiated without culture. •Obtain baseline vital signs and record. • WBC with differential may be done to detect typical changes After the Test associated with infection, such as leukocytosis (elevated •Monitor vital signs and urine output. WBC) and increased numbers of neutrophils. •Report manifestations of delayed reaction to the contrast media such as dyspnea, tachycardia, itching, hives, or flush- In men and in adult women with recurrent infections or per- ing. sistent bacteriuria, additional diagnostic testing may be ordered Client and Family Teaching to evaluate for structural abnormalities and other contributing •X-rays and a dye that is rapidly excreted in the urine and factors. X-rays are used to show the structures of the , , • Intravenous pyelography (IVP), also known as excretory and bladder.The test takes about 30 minutes. urography, is used to evaluate the structure and excretory •A laxative and possibly an enema or suppository are used function of the kidneys, ureters, and bladder. As the kidneys before the test to clear the bowel of feces and gas. Do not eat after the ordered time the evening before the test; you may clear an intravenously injected contrast medium from the drink clear fluids such as water, coffee, or tea (without blood, the size and shape of the kidneys, their calices and creamer). pelvises, the ureters, and the bladder can be evaluated, and •As the dye is injected, you may feel a transient flushing or structural or functional abnormalities, such as vesicoureteral burning sensation, along with possible nausea and a metallic reflux, may be detected. taste. • Voiding cystourethrography involves instilling contrast •Notify your doctor immediately if you develop a rash, diffi- medium into the bladder, then using X-rays to assess the culty breathing, rapid heart rate, or hives during or after the bladder and when filled and during voiding. This test. study can detect structural or functional abnormalities of the •Increase fluid intake after the test is completed. bladder and urethral strictures. This test has a lower risk of VOIDING CYSTOURETHROGRAPHY allergic response to the contrast dye than IVP. Preparation • , direct visualization of the urethra and bladder •Assess knowledge and understanding of the procedure, through a cystoscope, may be used to diagnose conditions clarifying information as needed. such as prostatic hypertrophy, urethral strictures, bladder cal- •Verify the presence of a signed consent for the procedure. culi, tumors, polyps or diverticula, and congenital abnormal- •Ask about allergy to seafood, iodine, or radiologic contrast ities. A tissue biopsy may be obtained during the procedure, dye. Notify physician or radiologist if allergies are known. Be- and other interventions performed (e.g., stone removal or cause the dye is not injected, allergic reactions are rare, and stricture dilation). allergy does not contraindicate the examination. • Manual pelvic or prostate examinations are done to assess •Instruct to consume only clear liquids the morning of the exam, or as recommended by radiology. for structural changes of the genitourinary tract, such as pro- •Insert indwelling if ordered. static enlargement, cystocele, or rectocele. CHAPTER 26 / Nursing Care of Clients with Urinary Tract Disorders 709

Men and women with pyelonephritis, urinary tract ab- Client and Family Teaching normalities or stones, or a history of previous infections with •The bladder is filled with dye solution and X-rays are taken antibiotic-resistant infections require a 7 to 10 day course of of the filled bladder and of the bladder and urethra during . TMP-SMZ, ciprofloxacin, ofloxacin (Floxin), or an alternate •This procedure causes little or no discomfort and takes antibiotic. The client with severe illness may need hospital- approximately 30 to 45 minutes to complete. ization. Intravenous ciprofloxacin, gentamicin, ceftriaxone •After the procedure, increase your fluid intake to help elimi- (Rocephin), or ampicillin may be prescribed for severe illness nate the contrast dye and to reduce burning on urination. or sepsis associated with UTI. See Chapter 8 for the nursing •Report signs of infection, such as frequency, urgency, painful implications for antibiotic therapy. urination, cloudy or bloody urine, or malodorous urine. The outcome of treatment for UTI is determined by follow- up urinalysis and culture. Cure, as evidenced by no pathogens CYSTOSCOPY present in the urine, is the desired outcome. When therapy fails Preparation to eradicate bacteria in the urine, it is known as unresolved bac- •Assess knowledge and understanding of the procedure, teriuria. Persistent bacteriuria or relapse occurs when a per- clarifying information as needed. sistent source of infection causes repeated infection after initial •Verify the presence of a signed consent for the procedure. cure. Reinfection is the development of a new infection with a •Instruct in pretest preparation as ordered, including pre- different pathogen following successful UTI treatment (Tierney scribed laxatives the evening prior to the test and any or- dered food or fluid restrictions. et al., 2001). •Administer sedation and other medications as ordered prior Clients who experience frequent symptomatic UTIs may be to the test. treated with prophylactic antibiotic therapy with a drug such as TMP-SMZ, TMP, or nitrofurantoin (Furadantin, Nitrofan). Client and Family Teaching TMP and nitrofurantoin do not achieve effective plasma con- •Cystoscopy is performed in a special cystoscopy room, using local or general anesthesia. You may feel some pressure or a centrations at recommended doses, but do reach effective con- need to urinate as the scope is inserted through the urethra centrations in the urine. Nitrofurantoin also may be used to into the bladder. The procedure takes approximately 30 to treat UTI in pregnant women. Nursing implications for these 45 minutes. urinary anti-infectives and for phenazopyridine (Pyridium), a •Do not attempt to stand without assistance immediately urinary analgesic, are outlined on page 000. after the procedure as you may feel dizzy or faint. Antibiotics and urinary anti-infectives are not generally rec- •Burning on urination for a day or two after the procedure is ommended to treat asymptomatic bacteriuria in catheterized to be expected. clients. The preferred treatment for catheter-associated UTI is •Immediately notify the physician if your urine remains removal of the indwelling catheter followed by a 10 to 14 day bloody for more than three voidings after the procedure, or course of antibiotic therapy to eliminate the infection. you develop bright bleeding, low urine output, abdominal or flank pain, chills, or fever. Surgery •Warm sitz baths, analgesic agents, and antispasmodic med- Surgery may be indicated for recurrent UTI if diagnostic test- ications may relieve discomfort after the procedure. •Increase fluid intake to decrease pain and difficulty voiding ing indicates calculi, structural anomalies, or strictures that and reduce the risk of infection. contribute to the risk of infection. Table 26–1 lists major causes •Laxatives may be ordered after the procedure to prevent of urinary tract obstruction that may contribute to UTI. constipation and straining, which may cause urinary tract bleeding. Table 26–1 Major Causes of Urinary Tract Obstruction by Location Location Obstructive Process Medications Kidney pelvis Calculi Most uncomplicated infections of the lower urinary tract can be Polycystic kidney disease treated with a short course of antibiotic therapy. Upper urinary Infection and scarring tract infections, in contrast, usually require longer treatment Ureters Calculi (2 or more weeks) to eradicate the infecting organism. Scarring and stricture Short-course therapy (either a single antibiotic dose or a Congenital defects or strictures External processes such as pregnancy, 3-day course of treatment) reduces treatment cost, increases tumors, lymph node enlargement compliance, and has a lower rate of side effects. Single dose Bladder Neurogenic bladder therapy is associated with a higher rate of recurrent infection Tumors and continued vaginal colonization with E. coli, making a Calculi and other foreign bodies 3-day course of treatment the preferred option for uncompli- Urethra Benign prostatic hypertrophy cated cystitis. Oral trimethoprim-sulfamethoxazole (TMP-SMZ), Tumors TMP, or a quinolone antibiotic such as ciprofloxacin (Cipro) Scarring and stricture Trauma or enoxacin (Penetrex) may be ordered.