Interventions for Clients with Urinary Problems
After studying this chapter, you should be able to:
1. Describe the clinical manifestations of cystitis.
2. Prioritize educational needs for a person at risk for cystitis.
3. Compare and contrast the pathophysiology and manifestations of stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, and functional incontinence.
4. Prioritize educational needs for the client taking sulfonamide antibiotics for a urinary tract infection.
5. Describe the techniques used to assess pelvic floor strength in the client who is experiencing some incontinence.
6. Explain the proper application of exercises to strengthen pelvic floor muscles.
7. Explain the drug therapy for different types of incontinence.
8. Prioritize nursing care for the client with renal colic.
9. Describe the common clinical manifestations of bladder cancer.
10. Develop a teaching plan for a client who has had a urinary diversion for bladder cancer.
Urinaró disorders affect the
storage or elimination of urine. Both acute and
chronic urinary problems are common and costly. More than 20 million people in
Infections of the urinary tract and kidneys occur
often. Symptoms of urinary tract infection (UTI) account for more
than 6.5 million health care visits annually in the United States, and 1.5 million hospital discharges involve a
diagnosis of UTI (Centers for Disease Control and Prevention [CDC], 2001). In the hospital, UTIs are the most prevalent
nosocomial infection (
The primary site of the infectious process describes infections in the urinary tract. Acute infections in the lower urinary tract include urethritis (urethra), cystitis (bladder), and pro-statitis (prostate gland). Acute pyelonephritis is an upper urinary tract (kidney) infection. It is important to determine the site of infection, since both the site of infection and the specific type of bacteria present determine treatment. A number of structural or functional abnormalities of the urinary tract and characteristics of the urine are thought to predispose clients to UTIs (Table 70-1).
Cystitis is an inflammation of the urinary bladder. It can be caused by infection from bacteria, viruses, fungi, or parasites. Infectious cystitis is the most common of the UTIs. Nonin-fectious cystitis is caused by chemicals or radiation. Interstitial cystitis is an inflammatory process of unknown etiology.
Infectious agents, most commonly bacteria, typically move up the urinary tract from the external urethra to the bladder. Less typically, spread of infection through the blood and lymph fluid can occur. Once bacteria enter the urinary tract, several factors influence the outcome (Table 70-2).
Asymptomatic bacteriuria is more common in older adults and is generally considered a benign condition. No studies have demonstrated a relationship between asymptomatic bacteriuria and progression to acute infection or renal insufficiency in clients without obstructive conditions, reflux, stones, or diabetes mellitus.
The most common pathogens in infectious cystitis are organisms from the gastrointestinal (GI) tract. It is estimated that 90% of UTIs are caused by Escherichia coli. Other, less common infective organisms include Staphylococcus sapro-phyticus, Klebsiella pneumoniae, and organisms from the Proteus and Enterobacter species.
In most cases, GI organisms first grow in the perineal
area; then move into the urethra as a result of irritation,
trauma, or instrumentation of the urinary tract (i.e., catheterization); and
ascend to the bladder. Catheters are the most common predisposing factor for UTIs in the hospital setting. Within
48 hours of catheter insertion, bacterial
colonization begins. About 50% of clients with indwelling catheters
become infected within 1 week of
catheterization. The etiology of catheter-related infections varies between genders. Bacteria from a female client's perineal area are more likely to
adhere to the outer surface of the
catheter and then ascend to the bladder. In male clients, bacteria tend to gain access to the bladder from inside the lumen of the catheter (
Organisms other than bacteria can cause cystitis. Fungal infections, such as those caused by Candida, may develop during long-term antibiotic therapy, since antibiotics alter normal flora. Clients who are severely immunocompromised and have decreased resistance to infection, are receiving glu-cocorticosteroids or other immunosuppressive agents, or have diabetes mellitus or acquired immunodeficiency syndrome (AIDS) are also at risk for fungal UTIs.
Viral and parasitic infections are rare and usually accompany an infection in another site. For example, Trichomonas, a parasite found in the vagina, can also be found in the urine. Treatment of the vaginal infection (see Chapter 75) is usually sufficient to treat the UTI.
Noninfectious cystitis may result from chemical exposure, such as to drugs (e.g., cyclophosphamide [Cytoxan, Procy-tox4*1]), from radiation therapy, and from immunologic responses, as with systemic lupus erythematosus (SLE).
Interstitial cystitis is a relatively rare, chronic inflammation of the bladder. The condition affects women more often than men (in a 12:1 ratio), and the diagnosis is difficult to make. The symptoms are identical to those of simple cystitis, but the urgency and bladder pain are more intense (Thompson & Christmas, 1996).
Although cystitis is not life threatening, infectious cystitis can lead to life-threatening complications, including pyelonephritis and sepsis. There is considerable debate about the risk for kidney tissue damage and subsequent kidney failure as a result of bacteria ascending from the bladder to the kidney. Most experts believe that severe deterioration of renal function is a rare complication without one or more predisposing factors, such as anatomic abnormalities, pregnancy, obstruction, reflux, calculi, or diabetes mellitus.
The spread of the infecting agent from the urinary
tract to systemic circulation is termed urosepsis.
Sepsis from any source is a
systemic infection that can lead to overwhelming organ failure, shock, and
death. The most common cause of sepsis in the
hospitalized client is a UTI (
The incidence of UTI is second only to that of upper respiratory infections in primary care. Clients who have the symptoms of frequency (an urge to urinate frequently in small amounts), dysuria (pain and/or burning with urination), and urgency (the feeling that urination will occur immediately) account for more than 5 million health care visits annually. Approximately 50% of these clients will have a confirmed UTI. Recurrent infections account for an unknown number of these visits (CDC, 2001).
WOMEN'S HEALTH CONSIDERATIONS The prevalence of UTIs varies with age and gender. Generally, women are more commonly affected with UTIs than men. In men 65 to 70 years old, the incidence of UTI is 3%; after age 70, however, the incidence is 20%. In women over the age of 80, the prevalence rises from 20% to 50% (Duffield, 1997). It is believed that skin and mucous membrane changes from a lack of estrogen account for much of the increased risk.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
Frequency, urgency, and dysuria are the primary clinical manifestations of a urinary tract infection (UTI), but other signs and symptoms may be present (Chart 70-2). Urine may be cloudy, foul smelling, or blood tinged. Identifying risk factors contributing to UTI are included in the assessment (see Table 70-1).
Before performing the physical assessment, the nurse asks the client to void so that the urine can be examined and the bladder emptied before palpation. The nurse assesses vital signs to help rule out sepsis, inspects the lower abdomen, and palpates the urinary bladder. Distention after voiding indicates incomplete bladder emptying.
Using standard precautions (see Chapter 26), the nurse notes inflammation and any skin lesions around the urethral meatus and vaginal introitus (opening). Female clients often report "burning with urination" when normal, acidic urine touches labial tissues that are inflamed and ulcerated by vaginal infections or sexually transmitted diseases (STDs). Privacy is maintained with drapes during the examination.
The prostate is palpated by rectal examination for size, alteration in contour, and any evidence of tenderness. The physician or advanced-practice nurse performs the rectal prostate assessment.
Laboratory evaluation for a UTI is usually a urinalysis with a microscopic count of bacteria, white blood cells (WBCs), and^red blood cells (RBCs). The presence of 100,000 colonies/mL and/or the presence of WBCs (pyuria) indicate an infection. A urinalysis is performed on a clean-catch midstream specimen. If the client cannot produce a clean-catch specimen, the nurse may need to obtain the specimen with a small-caliber (6 Fr) urethral catheter. For a routine urinalysis, 10 mL of urine is required; smaller quantities are sufficient for culture. A urine culture confirms the type of microorganism and the number of colonies. Urine culture is expensive and takes 48 hours to obtain results. It is indicated when the UTI is complicated or not responsive to usual therapy or if the diagnosis is uncertain. The presence of a UTI is confirmed when there are more than 105 colony-forming units in the urine from any client, although in a symptomatic client as few as 103 colony-forming units may be diagnostic. Multiple organisms in low colony counts generally indicate a contaminated specimen.
Sensitivity testing follows culture results, especially when complicating factors are present, such as stones or recurrent infection, or when the client is older.
Occasionally the serum WBC count may be elevated, with the differential WBC count showing "left shift." This shift indicates that the number of immature WBCs is increasing in response to the infectious organisms. Consequently, the number of bands, or immature WBCs, is elevated. Left shift most commonly occurs with urosepsis and rarely occurs with uncomplicated cystitis.
OTHER DIAGNOSTIC ASSESSMENT
The clinician usually bases the diagnosis of cystitis on the history, physical examination, and laboratory data. If urinary retention and obstruction to urinary outflow are suspected, urography, abdominal sonography, or computed tomography (CT) may be needed to determine the site of obstruction or the presence of calculi. Voiding cystourethrography (see Chapter 69) is used for the diagnosis of suspected cases of vesi-coureteral reflux.
Cystoscopy (see Chapter 69) is often performed when there is a history of recurrent UTIs (more than three or four a year). The urine is sterilized with antibiotic therapy before the procedure so that the risk of sepsis is not increased. Cystoscopy can identify abnormalities that may have contributed to the development of cystitis. These abnormalities include bladder calculi, bladder diverticula, urethral strictures, foreign bodies (such as sutures from previous surgery), and trabecu-lation (an abnormal thickening of the bladder wall caused by urinary retention and obstruction). Retrograde pyelography, along with the cystoscopic examination, produces outlines and images of the drainage tract. Areas of obstruction or malformation and the presence of reflux are then identified early.
Cystoscopy is the only means of accurately diagnosing interstitial cystitis. A urinalysis may show WBCs and RBCs but no bacteria. Classic findings in interstitial cystitis include a small-capacity bladder, the presence of Hunner's ulcers (a type of bladder lesion), and small hemorrhages after bladder distention.
DRUG THERAPY. Medications prescribed to treat bacteri-uria and promote comfort in the client with cystitis include urinary antiseptics or antibiotics, analgesics, and antispas-modics. The clinician prescribes antibiotics to treat any infection (Chart 70-3). Antifungal agents are administered when the infecting organism is a fungus. Amphotericin Â is most often given in daily bladder instillations, and ketoconazole (Nizoral) is given in oral or parenteral form. The antispasmodic agents decrease bladder spasm and promote complete bladder emptying.
Antibiotic therapy is the usual prescription for a UTI
(see Chart 70-3). Guidelines for UTIs in women
indicate that a 3-day course of trimethoprim/sulfamethoxazole or
fosfomycin is effective in eradicating an
WOMEN'S HEALTH CONSIDERATIONS Pregnant women require vigorous intervention when bac-teriuria is identified because of the tendency of simple cystitis to lead to acute pyelonephritis. Pyelonephritis in pregnancy can cause preterm labor and deleterious effects on the fetus.
Long-term antibiotic therapy is recommended for the treatment of chronic, recurring infections caused by structural abnormalities or calculi. Trimethoprim 100 mg daily may be prescribed for long-term management of the older client with frequent UTIs (Duffield, 1997). For women who experience recurrent UTIs after sexual intercourse, 1 low-dose tablet of nitrofurantoin (Macrodantin, Nephronex1^, Novofuran^) after intercourse is often recommended.
URINARY ELIMINATION. The goal is to maintain an optimal urinary elimination pattern. Interventions for the management of cystitis are highlighted in Chart 70-4.
DIET THERAPY. The diet should include all food groups and include a number of calories for the increased metabolic processes associated with infection. Unless medically con-traindicated, fluid intake needs to be at least 2 to 3 L/day for adequate flushing of urine through the system. Evidence suggests that 300 mL of cranberry juice consumed daily decreases bacterial adherence to the urinary tract, decreasing the incidence of UTIs in some clients. Cranberry juice must be consumed for 3 to 4 weeks to be effective (Walsh et al., 1998).
OTHER PAIN RELIEF MEASURES. A warm sitz bath taken two or three times a day for 20 minutes may provide comfort and some relief of local symptoms. If burning with urination is severe or urinary retention occurs, the nurse instructs the client to sit in the sitz bath and urinate into the warm water.
SURGICAL MANAGEMENT. Surgical interventions for clients with cystitis treat the conditions that predispose to recurrent UTIs (e.g., removal of obstructions, treatment of calculi, and repair of vesicoureteral reflux). Procedures may include cystoscopy (see Chapter 69) to identify and remove calculi or obstructions.
The nurse assesses the client's level of understanding from his or her description of the problem. The client's knowledge about factors contributing to the development of cystitis is the basis on which further teaching interventions are planned.
The client is instructed in self-administration of medications. Appropriate spacing of doses throughout the day and the need to complete all of the prescribed medication are stressed. If the drug will change the color of the urine, as it does with phenazopyridine (Pyridium, Pyronium), the nurse informs the client to expect this occurrence. The nurse offers techniques for remembering the medication schedule, such as
the use of a daily calendar or the association of medications with usual activities (e.g., mealtimes).
Clients may associate symptoms of discomfort with sexual activities and experience feelings of guilt and embarrassment. Frank and sensitive discussions with a woman who experiences frequent recurrences of UTI after sexual intercourse can help her find appropriate techniques to handle the problem (see Table 70-1). The nurse explores with the woman the factors that contribute to her postcoital infections, such as diaphragm use and her general resistance to infection. The client is reminded that vigorous cleaning of the perineum with harsh soaps and vaginal douching may irritate the perineal tissues and actually increase the risk of UTI. At the client's request, the nurse discusses the problem with the client and her partner to help them find ways of maintaining their intimate relationship. Chart 70-5 gives other specific instructions for preventing UTIs.
'Urethritis is an inflammation of the urethra that causes symptoms similar to urinary tract infection (UTI). In male clients, signs and symptoms of urethritis are burning or difficulty with urination and usually a discharge from the urethral meatus. The most common cause of urethritis in men is sexually transmitted diseases (STDs): gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a prevalent sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tract).
In female clients, urethritis causes symptoms similar to those of bacterial cystitis. Urethritis is known by several synonyms: pyuria-dysuria syndrome, frequency-dysuria syndrome, trigonitis syndrome, and urethral syndrome. Urethritis is most common in postmenopausal women and is probably caused by tissue changes related to low estrogen levels.
The nurse asks the client about a history of STD, painful or difficult urination, discharge from the penis or vagina, and internal discomfort in the lower abdomen. Urinalysis may show pyuria (white blood cells [WBCs]) without a significant number of bacteria; however, results of urethral culture may indicate an STD. In female clients, the diagnosis may be made by exclusion when urinalysis and urethral culture are negative for bacteria and symptoms persist. In such cases, pelvic examination may show symptoms of hypoestrogenism (tissue changes from low estrogen levels) in the vagina; cys-tourethroscopy may show hypoestrogenism with inflammation of urethral tissues.
STDs and infectious processes are treated with appropriate antibiotic therapy. Further information on STDs can be found in Chapter 74. Postmenopausal women with urethral syndrome often have improvement in their urethral symptoms with the use of estrogen vaginal cream. Estrogen cream applied locally to the vagina increases the amount of estrogen in the urethra as well, and irritating symptoms are reduced.
Urethral strictures are narrowed areas of the urethra. These problems may be caused by complications of an STD (usually gonorrhea) and from trauma during catheterization, urologic instrumentation, or childbirth. Strictures occur more often in men than in women and may be an important factor in other urologic conditions, such as recurrent UTIs, urinary incontinence, and urinary retention.
The most common symptom of urethral stricture is obstruction to the flow of urine; strictures rarely cause pain. Because stasis of urine can result when flow is obstructed, the client with a stricture is more likely to develop a UTI and have overflow incontinence. Overflow incontinence is the involuntary loss of urine when the bladder is overdistended. The nurse assesses the client for these two problems.
A urethral stricture is usually treated surgically. Dilation of the urethra (using a local anesthetic) is a temporary measure, not a curative one. The best chance of long-term cure is with urethroplasty, a surgical procedure in which the affected area is removed or grafted to create a larger opening for the passage of urine. The recurrence rate with surgical interventions is still high, and most clients need repeated procedures.
Continence (control over the time and place of urination) is a unique accomplishment of humans and certain domestic animals. Continence is a learned behavior whereby a person can suppress the urge to urinate until a socially appropriate (culturally prescribed) location is available (e.g., a toilet). Efficient bladder emptying (i.e., coordination between bladder contraction and urethral relaxation) is required for continence. Continence is learned in early childhood through toilet training and is generally accomplished by age 5 years.
Incontinence is an involuntary loss of urine severe enough to cause social or hygienic problems. Incontinence is not a normal consequence of aging or childbirth. Because of the stigma associated with incontinence and the belief that it is normal in the older adult, incontinence is one of the most underreported health problems. Many people suffer in silence, socially isolated and unaware that treatment is available.
The Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) chose urinary incontinence as one of its first topics for Clinical Practice Guidelines. The agency's goal is to educate the public and health care professionals about assessment and management of this condition (AHCPR, 1992, 1996).
Continence occurs when pressure in the urethra is greater than pressure in the bladder. For normal voiding to occur, the urethra must relax and the bladder must contract with sufficient pressure and duration to empty completely. Voiding should occur in a smooth and coordinated manner under a person's conscious control. The symptom of urinary incontinence has several possible causes and can be either temporary or chronic (Table 70-3). Temporary causes of incontinence are usually external to the urinary tract and involve no disorder of the urinary tract itself. The most common forms of urinary incontinence in adults are stress incontinence, urge incontinence, overflow incontinence, functional incontinence, and a mixed form.
The urethra can be relaxed and tightened under conscious control because skeletal muscles of the pelvic floor surround it. When a person feels the urge to urinate, the conscious con traction of the urethra can override a bladder contraction if the urethral contraction is strong enough.
Clients who suffer from stress incontinence cannot tighten the urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. The weakened pelvic floor contributes to mobility and displacement of the urethra during exertion. If the pelvic muscles are not properly strengthened, this condition continues. Decreasing amounts of estrogen after menopause also contribute to stress incontinence. Vaginal, urethral, and pelvic floor muscles become thin and weak without estrogen. Stress incontinence is the most common form of incontinence in women.
Bladder contractions are perceived as an urge to urinate. When the bladder is full, contraction of the smooth muscle fibers of the bladder detrusor muscle normally signals the brain that it is time to urinate. Continent persons override that signal and relax the detrusor muscle for the time it takes to locate a toilet. Those who suffer from urge incontinence cannot suppress the signal. Abnormal detrusor contractions may be a result of neurologic abnormalities or may occur with no known abnormality.
When the detrusor muscle fails to respond by contracting, the bladder becomes overdistended. Overflow incontinence (also known as reflex incontinence) occurs when the bladder has reached its absolute maximal capacity and some urine must leak out to prevent bladder rapture. Causes for the underactive (acontractile) bladder may or may not be determined.
The urethra can also be obstructed so that it fails to relax enough to allow urine flow. Incomplete bladder emptying or complete urinary retention due to urethral obstruction results in overflow incontinence.
Many clients with urinary incontinence fall into the mixed category. Their signs and symptoms have aspects of more than one of the major subtypes. This category is more common in older women.
Factors other than the abnormal function of the bladder and urethra also result in functional incontinence. The most common factor is a loss of cognitive function in clients affected by dementia. To maintain continence, a person must be aware that urination needs to occur in a socially acceptable place; clients with dementia may not have that awareness.
Incontinence may have temporary or permanent causes. Evaluation of the incontinent client means considering all possible causes, beginning with those that are temporary and correctable. Surgical and traumatic causes of urinary incontinence are usually related to procedures or surgery in the lower pelvic structures, areas that are richly supplied by complex nerve pathways. Radical urologic, prostatic, and gynecologic procedures associated with pelvic cancers may result in post-surgical urinary incontinence. Trauma that injures segments S2 to S4 of the spinal cord may cause incontinence from interruption of normal nerve pathways.
Inappropriate bladder contraction may result from disorders of the brain and nervous system or from bladder irritation due to chronic infection, stones, chemotherapy, or radiation therapy. Failure of bladder contraction accompanies the autonomic neuropathy associated with diabetes mellitus and syphilis. Costs associated with incontinence are enormous. The Cost of Care box below gives information about the individual and institutional considerations in providing continence care.
CONSIDERATIONS FOR OLDER ADULTS
Numerous factors contribute to the increased incidence of urinary incontinence in older adults (Chart 70-6). An older person may have decreased mobility from disease, neurologic dysfunction, or musculoskeletal degeneration. In the hospital or extended care setting, mobility is further limited when the older client is restrained or placed on bedrest. Vision and hearing impairments may also prevent the client from locating a call bell to notify the nurse or assistive nursing personnel of the need to void. The nurse assesses for these factors and, if possible, minimizes them to prevent urinary incontinence.
Urinary incontinence is a significant health problem
that affects more than 13 million people of all ages in the
In adult clients under 65 years of age, urinary incontinence occurs twice as often in women as in men. Incontinence in women of this age may occur after one or more pregnancies. Men in this age-group rarely experience urinary incontinence unless they have prostate disease or a spinal cord injury.
The nurse asks, "Do you ever leak urine?" If the answer is yes, the nurse proceeds with a focused assessment (Chart 70-7). Incontinence may be underreported because health care professionals do not question clients about urine loss. It is not safe to assume that clients will volunteer the information without specifically being asked.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The nurse assesses the abdomen to estimate suprapubic fullness, to rule out palpable hard stool, and to evaluate bowel sounds. With a physician's order, the nurse determines the amount of postvoid residual urine by catheterizing the client immediately after voiding. In some facilities, the nurse estimates the postvoid residual amount with a pelvic ultrasono-graphic scanner (AHCPR, 1996). Urinary incontinence is confirmed by evaluating the force and character of the urine stream during voiding by the client. Asking the client to cough while wearing a perineal pad may be useful in evaluating stress incontinence; a wet pad with forceful coughing may indicate stress incontinence (see the Evidence-Based Practice for Nursing box on p. 1625). A cystometrogram (see Chapter 69) is used as the basic diagnostic study in most cases (Walsh et al., 1998).
For women, the nurse inspects the external genitalia to determine whether there is apparent urethral or uterine prolapse, cystocele (herniation of the bladder into the vagina), or rec-tocele. These conditions occur because of pelvic floor muscle weakness. An advanced-practice nurse puts on an examination glove and inserts two fingers into the vagina to assess the strength of these muscles. Strength is described as weak, adequate, or strong on the basis of the amount of pressure felt by the nurse as the client tightens her vaginal muscles. The color, consistency, and odor of any secretions from the genitourinary orifices are described and documented. The urine stream interruption test (see Chapter 69) is another method of determining pelvic muscle strength. For men, the nurse inspects the urethral meatus for any discharge.
A digital rectal examination is performed on both male and female clients. The digital rectal examination may provide information about the integrity of the nerve supply to the bladder. The examiner determines whether there is tactile sensation in the anorectal area by noting whether the rectal sphincter is relaxed or contracted on digital insertion. Because nerve supply to the bladder is similar to nerve supply to the rectum, the presence of tactile sensation and a rectal sphincter that contracts suggest that the nerve supply to the bladder is intact. During rectal examination, the nurse also notes any fecal impaction. Enlargement of the prostate is assessed in men by the physician or advanced-practice nurse.
A urinalysis is inexpensive and useful to rale out infection. This test is the first step in the assessment of incontinent clients of any age. The presence of red blood cells (RBCs), white blood cells (WBCs), leukocyte esterase, or nitrites is an indication for culturing the urine. Any infection is treated before further assessment of incontinence.
Radiographic assessment is rarely indicated unless surgery is being considered. Excretory urography is the most useful for locating the kidneys and ureters. A voiding cystourethrogram (VCUG) may be performed to assess the size, shape, support, and function of the bladder; look for obstruction (especially prostate obstruction in men); and assess for postvoid residual (PVR) with a postvoid fdm. An assessment of PVR also can be made with a portable ultrasonographic bladder scanner.
OTHER DIAGNOSTIC ASSESSMENT
Clients who have unusual symptoms, medical complications, or a history of failed incontinence surgery often undergo uro-dynamic studies to determine the cause of their incontinence. A urodynamic evaluation is not a standardized procedure and may consist of any combination of the following tests:
Cystourethroscopy to examine the inside of the bladder and urethra directly
· Cystometrogram (CMG) to measure the pressure inside the bladder as it fills
· Urethral pressure profilometry (UPP) to measure the pressure in the urethra in relation to the bladder pressure during various activities
· Uroflowmetry to measure speed and completeness of bladder emptying
Testing may take several hours and more than one visit (see Chapter 69). Electromyography (EMG) of the pelvic muscles may be a part of the urodynamic studies. A perineometer is a tampon-shaped instrument inserted into the vagina to measure the strength of pelvic muscle contractions. The graph can be used to demonstrate the amplitude of muscle contraction to the client as a method of biofeedback.
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are priority nursing diagnoses for clients with urinary incontinence (AHCPR, 1996):
1. Stress Urinary Incontinence related to weak pelvic muscles and structural supports
2. Urge Urinary Incontinence related to decreased bladder capacity, bladder spasms, and neurologic impairment
3. Reflex Urinary Incontinence related to incomplete bladder emptying
4. Mixed or Total Urinary Incontinence related to multiple causes
5. Functional Urinary Incontinence related to cognitive, motor, or sensory deficits
■ ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the common nursing diagnoses, clients with urinary incontinence may have one or more of the following:
· Social Isolation related to altered state of wellness or fear of embarrassment
· Risk for Impaired Skin Integrity related to external risk factors, such as urinary excretions
· Disturbed Body Image related to odor, need to alter clothing selections, or need to wear protective briefs or supplies
· Risk for Infection related to retained or refluxing urine
Planning and Implementation
Several interventions are useful for each type of incontinence and for mixed incontinence. Collaborative management uses these interventions, as well as medication, surgical repair, and diet therapy.
STRESS URINARY INCONTINENCE
PLANNING: EXPECTED OUTCOMES. The client with urinary incontinence is expected to have fewer episodes of stress incontinence or a decreased amount of urine lost with each episode.
INTERVENTIONS. Initial interventions for clients with stress incontinence include diary keeping, behavioral interventions, and medications. Surgery is reserved as an option. The nurse explains the purpose of a detailed diary in which the client records times of urine leakage, activities, and foods eaten. The diary is then used by the health care practitioner to plan and evaluate interventions. Collection devices, absorbent pads, and undergarments may be used during the sometimes lengthy process of assessment and treatment and by those clients who elect not to pursue further interventions.
NONSURGICAL MANAGEMENT. Drag therapy and behavioral interventions (primarily diet and exercise) for stress incontinence require active participation on the part of the client for success. The ongoing availability of a nurse to provide encouragement, clarification, and support is extremely valuable for maximizing the effects of all interventions.
EXERCISE THERAPY. Pelvic floor (Kegel) exercises for female clients with stress incontinence are designed to strengthen the muscles of the pelvic floor (circumvaginal muscles). These muscles become strengthened, as any other skeletal muscle does, by frequent, systematic, and repeated contractions.
The most important step in teaching pelvic muscle exercises is to help the client become aware of which muscle to exercise. During the pelvic examination in women and the rectal examination in men or women, the nurse instructs the client to tighten the pelvic muscles around the examiner's fingers. The nurse then provides feedback about the strength of the contraction. Biofeedback devices, such as electromyography (EMG) or perineometers (see earlier discussion), measure the strength of contraction. Retention of a vaginal weight is also evidence that the client has identified the proper muscle. The ability to start and stop the urine stream or stop the passage of flatus is further evidence that the client has correctly identified the pelvic muscles.
Instructions for pelvic muscle exercises are given in Chart 70-8. Although improvement may take several months, most clients notice a significant change after 6 weeks. Clients may need to continue the exercises to maintain the improvement (AHCPR, 1996).
DIET THERAPY. A diet plan to encourage weight reduction is helpful for obese clients because stress incontinence is made worse by increased abdominal pressure from obesity. The nurse instructs the client to avoid alcohol and caffeine (bladder irritants) and refers him or her to the dietitian as needed.
DRUG THERAPY. Because bladder pressure is greater than urethral resistance in clients with stress incontinence, medications may be prescribed to increase the resistance of the urethra (Chart 70-9). Beta-adrenergic blocking agents, such as propranolol (Inderal, Detensol+O, have not been adequately tested in controlled trials and thus are not recommended for the treatment of incontinence (AHCPR, 1996).
Estrogen is used to treat postmenopausal women with stress incontinence, although its exact mechanism of action is unknown. Estrogen may increase the blood flow and tone of the circumvaginal and periurethral muscles, thus improving the client's ability to contract those muscles during times of increased intra-abdominal stress.
VAGINAL CONE THERAPY. Vaginal cones are a set of five small, cone-shaped weights. They are of equal size but of varying weights and are used with pelvic muscle exercise. The woman inserts the lightest cone, labeled 1, into her vagina (Figure 70-1), with the string to the outside, for a 1-minute test period. If she can hold the first cone in place without its slipping out while she walks around, she proceeds to the second cone, labeled 2, and repeats the procedure. The client begins her treatment with the heaviest cone she can comfortably hold in her vagina for the 1-minute test period. Treatment periods are 15 minutes twice a day. When she can comfortably hold the cone in her vagina for the 15-minute period, the client progresses to the next heaviest weight. Treatment is completed with the cone labeled 5.
Several studies have shown weighted vaginal cones to be helpful in strengthening the pelvic muscles and decreasing stress incontinence (AHCPR, 1996). Further research is needed, however, before recommending the weights to clients with pelvic prolapse. Vaginal cones are available without prescription, and the cost may be reimbursable by some health insurance companies.
OTHER THERAPY. Other types of interventions for stress incontinence include behavior modification, psychotherapy, and electrical stimulation devices to strengthen urethral contractions. A variety of intravaginal and intrarectal electrical stimulation devices have been used to treat neurologically and nonneurologically impaired clients with varying degrees of success. More research is needed to determine the ideal level of stimulation and methods of reducing the associated discomfort before electrical stimulation becomes a standard treatment for incontinence.
The Reliance insert is like a tiny tampon that the client inserts into the urethra. After insertion, the client inflates a tiny balloon, which rests at the bladder neck and prevents the flow of urine. To void, the client pulls a string to deflate the balloon and removes the device. The applicator is reusable, although the tampon part is disposed of after each void (Gallo, 1997).
SURGICAL MANAGEMENT. Stress incontinence may be surgically corrected by vaginal, abdominal, or retropubic procedures. Success rates vary between 50% and 90% for most procedures, but these rates are difficult to evaluate because of the varying definitions of "cure" in the studies. Furthermore, cure may vary between short-term and long-term (over 5 years) results. In addition, published complication rates are significant, ranging from less than 2% for collagen or silox-ane injection to 50% for bladder neck suspension.
PREOPERATIVE CARE. The nurse instructs the client about the surgical procedure and clarifies events surrounding the surgery. Extensive urodynamic testing (see Chapter 69) is often performed before surgery, and the need for such thorough assessment should be explained to the client.
OPERATIVE PROCEDURES. The surgical procedures used for women are designed to reposition the urethra and bladder, change the structure of the involved tissues, or insert artificial devices to improve function (Table 70-4).
POSTOPERATIVE CARE. After surgery, the nurse assesses for and intervenes to prevent or detect complications. For prevention of unnecessary movement or traction on the bladder neck, the urethral catheter is secured with tape or a tube holder. If a suprapubic catheter is present instead of a urethral catheter, the dressing is monitored for leakage of urine, as well as serosanguineous drainage. Catheters are usually in place until the client can urinate easily and has postvoid residual urine of less than 50 mL. (See Chapters 17 and 19 for a thorough discussion of general preoperative and postoperative care.)
URGE URINARY INCONTINENCE
PLANNING: EXPECTED OUTCOMES. The client with urinary incontinence is expected to use techniques to prevent or manage urge incontinence.
INTERVENTIONS. Interventions for clients with urge incontinence, sometimes called "overactive bladder" by the lay public, include behavioral interventions and medications. Surgery is not recommended for treatment of this condition. Collection devices and absorbent pads and undergarments may be used.
DRUG THERAPY. Because the hypertonic bladder contracts involuntarily in clients with urge incontinence, medications that relax the smooth muscle and increase the bladder's capacity are prescribed (see Chart 70-9).
The most effective medications are anticholinergics, such as propantheline (Pro-Banthine, Ðãîðàïòå1Ô), and anticholinergics with smooth muscle relaxant properties, such as oxybu-tynin (Ditropan) and dicyclomine hydrochloride (Bentyl, For-mulex^, Spasmoban^, Visceral1*1). Anticholinergics have serious side effects and are therefore used in conjunction with behavioral interventions. These agents inhibit the cholinergic fibers that stimulate bladder contraction. Tricyclic antidepres-sants with anticholinergic and alpha-adrenergic agonist activity, such as imipramine (Tofranil, Novopramine1*1), have been used successfully. Other drugs, such as flavoxate (Urispas) and the antihistamines, nonsteroidal anti-inflammatory agents, beta-adrenergic agonists, and calcium channel blockers, have not been studied well enough for their use to be recommended (AHCPR, 1996).
DIET THERAPY. The nurse instructs the client to avoid foods that have a direct bladder-stimulating or diuretic effect, such as caffeine and alcohol. Spacing fluids at regular intervals throughout the day (e.g., 120 mL every hour or 240 mL every 2 hours) and limiting fluids after the dinner hour (e.g., only 120 mL at bedtime) help avoid placing a fluid overload on the bladder and allow urine to accumulate at a steady pace.
BEHAVIORAL INTERVENTIONS. Behavioral interventions for urge incontinence include bladder training, habit training, exercise therapy, and electrical stimulation.
NIC interventions for urinary bladder training and urinary habit training are presented in Chart 70-10. It can be difficult for clients to understand these interventions because they involve a significant amount of participation on their part. The ongoing availability of a nurse to provide encouragement, clarification, and support is extremely valuable for maximizing the effects of all interventions. Behavioral interventions are often combined with drug therapy for maximal effect.
BLADDER TRAINING. Bladder training is primarily an education program for the client that begins with a thorough explanation of the problem of urge incontinence. Instead of the bladder being in control of the client, the client learns to control the bladder. For the program to succeed, he or she must be alert, aware, and able to resist the urge to urinate.
A regular schedule for voiding is established, beginning with the longest interval that is comfortable for the client, even if the interval is only 30 minutes. The nurse instructs the client to void every 30 minutes and ignore any urge to urinate between the mandated intervals. Once the client is comfortable with the initial schedule, the interval is increased by 15 to 30 minutes; the new schedule is followed until the client again achieves success. As he or she progressively increases the voiding interval, the bladder gradually tolerates more volume. The client is taught relaxation and distraction techniques to maximize success in the retraining. The nurse provides positive reinforcement for maintaining the prescribed schedule.
HABIT TRAINING. Habit training (scheduled toileting) is a variation of bladder training that has been successful in reducing incontinence in cognitively impaired clients. To use habit training, caregivers assist the client in voiding at specific times (e.g., every 2 hours on the even hours) in an effort to get him or her to the toilet before incontinence can occur. There is no effort to increase bladder capacity by gradually lengthening the voiding intervals.
Prompted voiding, a supplement to habit training, attempts to increase the client's awareness of the need to void and to prompt him or her to ask for toileting assistance. Habit training otherwise relies completely on a time schedule.
EXERCISE THERAPY. Pelvic muscle exercises for urge incontinence have been helpful and are taught in the same way as for stress incontinence (see Chart 70-8). Improved urethral resistance enhances the client's ability to overcome abnormal detrusor contractions long enough to get to the toilet.
ELECTRICAL STIMULATION. A variety of intravaginal and intrarectal electrical stimulation devices have been used to treat both urge and stress incontinence.
REFLEX URINARY INCONTINENCE
PLANNING: EXPECTED OUTCOMES. The client with urinary incontinence is expected to achieve continence by keeping urine volume in the bladder within normal limits, preventing bladder overdistention.
INTERVENTIONS. Interventions for the client with reflex (overflow) incontinence caused by obstruction of the bladder outlet may include surgery to relieve the obstruction. The most common surgical procedures are removal of the prostate (see Chapter 76) and repair of genital prolapse (see Chapter 75). For overflow incontinence related to detrusor muscle inadequacy, the most effective method of treatment is intermittent catheterization. Behavioral interventions such as bladder compression and intermittent self-catheterization are the primary management techniques for urinary retention leading to overflow incontinence.
DRUG THERAPY. Medications are prescribed for short-term management of urinary retention, often postoperatively. They are not indicated in long-term management of the hypo-tonic bladder resulting in overflow incontinence. The most commonly used medication is bethanechol chloride (Ure-choline), a cholinergic agent that increases bladder pressure.
BEHAVIORAL INTERVENTIONS. The mainstays of behavioral interventions include methods for bladder compression and intermittent self-catheterization.
BLADDER COMPRESSION. Techniques that promote bladder emptying include the Crede method, the Valsalva maneuver, double-voiding, and splinting.
In the Crede method, the nurse instructs the client in external compression of the urinary bladder or parasympathetic stimulation via tugging at pubic hair or massaging the genital area. These techniques manually assist the bladder in emptying. In the Valsalva maneuver, breathing techniques increase intrathoracic and intra-abdominal pressure. This increased pressure is then directed toward the bladder during exhalation. With the technique of double-voiding, the client empties the bladder and then, within a few minutes, consciously attempts a second bladder emptying.
For women who have a severe cystocele (prolapse of the bladder into the vagina), a technique called splinting both compresses the bladder and moves the obstruction out of the way. The woman inserts her own fingers into her vagina, gently pushes the cystocele back into the vagina, and begins to urinate.
INTERMITTENT SELF-CATHETERIZATION. NIC interventions for intermittent urinary catheterization are presented in Chart 70-10. The nurse teaches intermittent self-catheteri-zation to clients with long-term problems of incomplete bladder emptying. Techniques of self-catheterization are well established and can be learned fairly easily. The nurse remembers the following important points in teaching this technique:
· Proper handwashing and cleaning of the catheter reduce the frequency of infection.
· A small lumen and adequate lubrication of the catheter prevent urethral trauma.
· A regular schedule for bladder emptying prevents overdistention of the bladder with subsequent mucosal trauma.
Clients must be able to understand instructions and have the manual dexterity to manipulate the catheter. Caregivers or family members in the home can also be taught to perform straight catheterization using a clean (rather than sterile) technique with good outcomes.
FUNCTIONAL URINARY INCONTINENCE
PLANNING: EXPECTED OUTCOMES. The client with urinary incontinence is expected to use methods of urine containment or collection that ensure dryness until the underlying cause of the incontinence is treated.
INTERVENTIONS. Causes of functional (or chronic intractable) incontinence vary greatly; some are reversible, and others are not. The primary focus of intervention is treatment of reversible causes. When incontinence is not reversible, urinary habit training (see Habit Training, p. 1629) is done to establish a predictable pattern of bladder emptying to prevent incontinence regardless of the cause(s). A final strategy focuses on containment of the urine and protection of the client's skin. Nonsurgical interventions include applied devices, containment, and urinary catheterization.
APPLIED DEVICES. Applied devices include intravaginal pessaries for women and penile clamps for men. The intravaginal pessary supports the uterus and vagina and helps maintain the correct position of the bladder. (See Chapter 75 for further discussion of pessaries.) The penile clamp is applied externally to compress the urethra and prevent leakage of urine.
The dangers of pessaries and penile clamps include damage to the tissues and infection from constant pressure in sensitive areas. Both devices require that the client have manual dexterity or a caregiver who applies and removes the device. The clinician prescribes the device, and the nurse instructs the client or caregivers in its use. Male clients may use an external collecting device, such as a condom catheter. Design of a suitable external collecting device for women has not been as successful.
CONTAINMENT. Absorbent pads and briefs are designed to collect urine and keep the client's skin and clothing dry. A variety of types and sizes of pads are available: Shields or liners inserted inside a panty
· Undergarments consisting of full-sized pads with waist straps
· Plastic-lined protective underpants with or without elastic legs
· Combination pad and pant systems
· • Absorbent bed pads
A major concern with the use of protective pads is the risk that skin breakdown will occur. Materials and costs vary; some are reusable, and others are disposable. The disposal of these products raises ecologic concerns. Newer, more absorbent products are coming on the market as manufacturers take advantage of the growth of the "adult diaper" market. The nurse avoids use of the word "diaper," however, because of the usual association of diapers with a baby.
URINARY CATHETERIZATION. Catheterization for the control of incontinence may be intermittent or involve placement of an indwelling catheter. Intermittent self-catheterization is preferred to placement of an indwelling catheter because of the decreased likelihood of infection. Indwelling urinary catheters should be used temporarily and only when all other alternatives have been tried and have been unsuccessful. A long-term indwelling urinary catheter is appropriate for clients with skin breakdown who need a dry environment for healing, clients who are terminally ill and need comfort, and clients who are acutely or critically ill and require careful measurement of urine output.
CRITICAL THSNKiNG CHALLENGE Ö
Your client is diagnosed with mixed stress and urge incontinence. Her environment has no barriers to toileting, and she is able to ambulate in her home with the walker. Your client reports drinking about four cups of coffee daily.
• What effect does coffee have on continence?
• What exercises can you teach and reinforce in relation to continence care?
• How can you help evaluate your client's response to exercise and/or prescribed medication to improve continence?
Community-based care for the client with urinary incontinence considers his or her personal, physical, emotional, and social resources. Important personal resources for self-care include mobility, vision, and manual dexterity. The nurse considers who will be the primary caregiver and what environmental circumstances or factors will influence the effectiveness of the plan.
The nurse teaches the client and family or significant others about the cause of the identified type of urinary incontinence and discusses treatment options available for its management. The teaching plan addresses the prescribed medications (purpose, dosage, method and route of administration, and expected and potential side effects). The client and family are also instructed about the importance of weight reduction and dietary modification to assist with control of urinary incontinence.
When external devices or protective pads are needed, the nurse describes the possible options, discusses the advantages and disadvantages of each, and helps the client make a selection that considers lifestyle and resources. For clients who will use intermittent catheterization or those with artificial urinary sphincters, the nurse demonstrates the appropriate technique to the client or caregiver. Return demonstrations are evaluated for correct technique. Chart 70-11 also addresses teaching.
The embarrassment experienced by incontinent clients can be devastating to their self-esteem, body image, and interpersonal relationships. The unpredictability of incontinence creates anxiety. Clients are often embarrassed to seek help, and even when resources are identified, they may need assistance to feel comfortable in using the resources. Even buying supplies in the local drugstore or grocery store can be perceived as a threat to their privacy.
The nurse assists in psychosocial preparation by accepting and acknowledging the personal concerns of the client and caregiver. These concerns must never be minimized or made to seem trivial. The nurse helps the client learn methods of controlling or managing the fear or anxiety. As the client learns the specifics of the plan that will allow control of urinary incontinence, the confidence to resume psychosocial interactions should return.
HOME CARE MANAGEMENT
The home environment is assessed for barriers that impede access to the toileting facilities. Environmental hazards that might slow walking or contribute to injury are eliminated. These hazards might include small area rugs (throw rugs), tables or chairs with legs that extend into the walking area, slippery waxed or polished floors, and inadequate lighting.
If the client must climb stairs to reach a bathroom, handrails should be installed and stairs should be kept free of obstacles. Toilet seat extenders may help provide the appropriate level of seating so that maximal abdominal pressure may be applied to encourage voiding. Portable commodes may be obtained for homes in which ambulatory access to toilets is impractical or impossible. Physical and occupational therapists are valuable resources for assisting with home care management.
HEALTH CARE RESOURCES
Referral to home care agencies for assistance with personal care and to continence clinics that specialize in evaluation and treatment may be helpful. In many continence clinics, nurses collaborate with physicians and other health care professionals to evaluate and manage clients. The treatment plan is specific for each client; supplies and products are custom selected.
Clients benefit emotionally from education and from the support of others who experience similar concerns. The National Association for Continence (NAFC) and the Simon Foundation for Continence publish newsletters with informative articles and educational materials written with simple, easy-to-understand explanations. The Agency for Healthcare Research and Quality (AHRQ) has also published a caregiver guide (AHCPR Pub. No. 96-0683) for the public that is available on the Internet or by calling (800) 358-9295. Local hospitals, in collaboration with the NAFC, may conduct local support groups.
The nurse evaluates the care of the client with urinary incontinence on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client will:
Describe the type of urinary incontinence experienced Demonstrate knowledge of proper use of medications and correct procedures for self-catheterization, use of the artificial sphincter, or care of an indwelling urinary catheter
· Demonstrate effective use of the selected exercise or bladder training program
· Select and use incontinence devices and products
· Have a reduction in the number of incontinence episodes
Urolithiasis is the presence of calculi (stones) in the urinary tract. Stones are generally asymptomatic until they pass into the lower urinary tract, where they can cause excruciating pain. The term nephrolithiasis describes a condition in which stones form in the kidney. Formation of stones in the ureter is ureterolithiasis.
Urologic stones result from a variety of metabolic disorders. However, the exact mechanism of stone formation, commonly referred to as stone disease, is not entirely understood. Everyone excretes crystals in the urine at some time, but fewer than 10% of people form calculi. About 75% of calculi contain calcium as one component of the stone complex, which may be calcium oxalate or calcium phosphate (Hruska, 1996). Struvite (15%), uric acid (8%), and cystine (3%) make up the less common stones (Balaji &Menon, 1997).
Formation of stones seems to involve three conditions: Slow urine flow, resulting in supersaturation of the urine with the particular element (such as calcium) that first becomes crystallized and later becomes the stone Damage to the lining of the urinary tract (i.e., from crystals)
Decreased inhibitor substances in the urine that would otherwise prevent supersaturation and crystal aggregation High urine acidity (as with uric acid and cystine stones) or alkalinity (as with calcium phosphate and struvite stones) also contributes to stone formation.
One example of a metabolic problem causing stone formation begins when excessive amounts of calcium are absorbed through the intestinal tract (the most common cause of hyper-calciuria). As blood circulates through the kidneys, the excess calcium is filtered into the urine, causing supersaturation of calcium in the urine. If fluid intake is inadequate, such as when a client is dehydrated, supersaturation is more likely to occur, and there is an increased risk of calcium combining with another compound to form a larger molecule. The calcium complex often serves as a center for additional deposition, and eventually a stone forms.
Stones that form in the kidney and then pass into the ureter often lodge in the ureteropelvic angle, the aortoiliac bend, or the ureterovesical angle. When the calculus occludes the ureter and blocks the flow of urine, the ureter dilates. An enlargement of the ureter is called hydroureter.
The pain associated with ureteral spasm is excruciating and may cause the client to go into shock from stimulation of nearby sympathetic nerves. In addition, hematuria (bloody urine) may result from damage to the urothelial lining. If the obstruction is not removed, urinary stasis may result in infection and impair kidney function on the side of the blockage. As the blockage persists, hydronephrosis (enlargement of the kidney caused by blockage of urine lower in the tract and filling of the kidney with urine) and irreversible kidney damage, although rare, may develop.
The cause of urolithiasis is unknown, although several hypotheses have been suggested. At least 90% of clients with calculi have a contributing metabolic risk factor. Table 70-5 summarizes the known metabolic defects that commonly cause stone formation.
A diet high in calcium is not believed to cause stones unless a metabolic defect or renal tubular defect already exists. Even in clients with a history of nephrolithiasis, taking calcium citrate supplements does not cause new stone formation (Parivar, Low, & Stoller, 1996). Urinary stasis, urinary retention, immobilization, and dehydration all contribute to a calculus-forming environment. Except for the use of the thiazides for calcium oxalate stones, diuretics can cause volume depletion and thus may promote the formation of calculi.
The incidence of stone disease in the adult population is relatively high and varies with geographic location, race, and family history. About 12% of adults will have at least one episode of renal stone disease. Overall, the incidence is higher in men; however, struvite calculi are twice as common in women. Recurrence rates vary, depending on the type of treatment. The recurrence rate of untreated calcium oxylate stones is 35% to 50% in 5 to 10 years. A higher recurrence of stones is found in those clients with a family history of stone disease and those who had their first occurrence by age 25 years.
is an increased incidence of stone disease in the southeastern
The client is asked about a personal or family history of uro-logic stones. A diet history, including fluid intake patterns, is also obtained. If the client has a history of calculus formation, the nurse asks about past treatment, whether chemical analysis of the stone was performed, and what preventive measures the client follows.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The major clinical manifestation of calculi is severe pain, commonly called renal colic. Flank pain suggests that the stone is in the kidney or upper ureter. Flank pain that radiates abdominally or into the scrotum and testes or the vulva suggests that stones are in the ureters or bladder. Pain is most intense when the stone is moving or when the ureter is obstructed (Walsh et al., 1998).
Renal colic begins suddenly and is usually described as "unbearable." Nausea, vomiting, pallor, and diaphoresis often accompany the pain. A large stationary stone in the kidney (staghorn calculus), however, rarely causes much pain. Frequency and dysuria occur when a stone reaches the bladder.
Hematuria is a common finding; blood may make the urine appear smoky or rusty. Increased turbidity and odor are associated with infectious processes that may accompany urolithi-asis. Oliguria (scant urine output) or anuria (absence of urine output) suggests obstruction, possibly at the bladder neck or urethra. Obstruction of the urinary tract is an emergency and must be treated immediately to preserve kidney function.
The nurse examines the client to detect bladder distention. The physical examination may reveal pale, ashen, diaphoretic skin; the client may suffer from excruciating pain. Vital signs may be moderately elevated with pain; body temperature and pulse are elevated with infection. Blood pressure may decrease markedly if the severe pain causes shock.
Urinalysis may show red blood cells (RBCs), white blood cells (WBCs), and bacteria. RBCs are most likely the result of direct trauma, caused by the stone, on the endothelial lining of the ureter, bladder, or urethra. WBCs and bacteria may be present as a result of urinary stasis. Urine culture reveals infection (associated with struvite stones); sensitivity studies of the culture identify antibiotic effectiveness. Microscopic examination of the urine may identify crystals from which stones could form. Urinary pH is measured to determine acidity or alkalinity.
The serum WBC count is elevated with infection. Increases in the serum calcium, serum phosphate, or serum uric acid levels suggest that excess minerals are present and may contribute to stone formation.
Stones are easily seen on x-ray films of the kidneys, ureters, and bladder (KUB); IV urograms; or computed tomography (CT) scans. The primary purpose of these radiographic procedures is to confirm the presence and location of the calculi. The urogram is useful for identifying whether urinary tract obstruction is present; however, because of the risk of acute renal failure induced by contrast media, other diagnostic tests may be chosen for high-risk clients (older adults and clients who have diabetes mellitus, multiple myeloma, or elevated serum creatinine levels). CT is generally needed to identify cystine or uric acid stones, neither of which are visible on x-ray examination.
OTHER DIAGNOSTIC ASSESSMENT
Renal ultrasonography produces images from sound waves. Structures of varying density are reproduced. Solid structures, such as stones, are extremely dense; therefore the images of stones are clear. The identification of small stones and their exact location, however, may not be as precise as desired.
Nursing interventions are focused on pain management and prevention of infection and urinary obstruction. The majority of clients will be able to expel the stone without invasive procedures. The most important factors regarding whether a stone will pass on its own are its composition, size, and location. The larger the stone and the higher up in the urinary tract it is, the less likely it is to be passed. Other interventions may be necessary when the client does not pass the stone spontaneously (Figure 70-2).
PAIN RELIEF MEASURES. Nonsurgical and surgical approaches are used to assist the client with a kidney stone in achieving an acceptable degree of pain relief.
DRUG THERAPY. Pain is usually most severe in the first 24 to 36 hours. Opioid analgesics are often required to control the moderately severe to severe pain caused by stones in the urinary tract. Opioid agents, such as morphine sulfate (Statex1*1), are often administered intravenously so that prompt and adequate absorption is ensured. Nonsteroidal anti-inflammatory drugs such as ketorolac (Toradol) in the acute phase may be quite effective. Control of pain is more effective when medications are given at regularly scheduled intervals or via a constant delivery system (e.g., skin patch) instead of as needed (prn). Spasmolytic agents, such as oxybutynin chloride (Ditropan) and propantheline bromide (Pro-Banthine, Propan^d1*1), are extremely important for the relief and control of pain (see Chart 70-9). The nurse administers the medication and assesses the response by asking the client to rate the discomfort on a rating scale.
COMPLEMENTARY AND ALTERNATIVE THERAPY.
Relaxation techniques, such as hypnosis and imagery, therapeutic or healing touch, and acupuncture, can relieve pain. Clients often have great difficulty finding a comfortable position in which to relax; assisting the client with positioning can often aid in relaxation. Breathing techniques, such as those used in childbirth, can also help clients to relax.
OTHER MANAGEMENT TECHNIQUES. Avoiding over-hydration in the acute phase helps to make the spontaneous passage of a stone less painful (Singal & Denstedt, 1997). The nurse strains the urine to monitor for excretion of the calculus. Any stones obtained are sent to the laboratory for analysis; preventive therapy is based on stone composition.
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY. Lithotripsy, also known as extracorporeal shock wave lithotripsy (ESWL), is the application of sound, laser, or dry shock wave energies (electrohydraulic, electromagnetic, or piezoelectric) to break the stone into small fragments. The client receives conscious sedation and lies on a flat x-ray-type table with the lithotriptor aimed at the stone, which is visualized by fluoroscopy. A local anesthetic cream is applied to the skin focal site 45 minutes before the procedure.
During the procedure, cardiac rhythm is monitored by electrocardiography (ECG), and the shock waves are administered in synchrony with the R wave; 500 to 1500 shock waves are administered in 30 to 45 minutes. Continuous ECG monitoring for dysrhythmia and fluoroscopic observation for destruction of the stone are maintained.
After lithotripsy, the nurse may strain the urine to monitor the elimination of stone fragments. Some bruising may occur on the flank of the affected side after extracorporeal shock wave lithotripsy (ESWL).
Occasionally a stent is placed in the ureter before ESWL to facilitate passage of the stone fragments. Cystine stones are generally resistant to ESWL.
Various minimally invasive surgical and open surgical procedures are indicated if urinary obstruction occurs or if the stone is too large to be passed spontaneously.
MINIMALLY INVASIVE SURGICAL PROCEDURES.
Minimally invasive surgical (MIS) procedures include stenting, retrograde ureteroscopy, percutaneous antegrade nephrostoureterolithotomy, and laparoscopic ureterolithotomy.
Stenting. A stent is a small tube that is placed in the ureter through the endoscopic procedure of ureteroscopy. The stent dilates the ureter and creates a passageway for the stone or stone fragments. This procedure prevents the passing stone from coming in contact with the ureteral mucosa, thereby reducing pain. A Foley catheter also may be placed to facilitate passage of the stone through the urethra.
Retrograde Ureteroscopy. Retrograde ureteroscopy is an endoscopic procedure. The ureteroscope is passed through the urethra and bladder into the ureter. Once the stone is seen, it can be removed using grasping baskets, forceps, or loops. Through the ureteroscope, lithotripsy also can be performed. A Foley catheter also may be placed to facilitate passage of the stone fragments through the urethra.
Percutaneous Antegrade Nephrostoureterolithotomy. In percutaneous antegrade nephrostoureterolithotomy, the client lies prone, or laterally and receives general anesthesia. The physician identifies the ideal kidney entry point with fluoroscopy and then passes a needle into the collecting system of the kidney. Once a tract has been made in the kidney, other equipment, such as an intracorporeal (inside the body) ultrasonic or laser lithotriptor, can be used to break up and remove the stone. An endoscope with a special attachment to grasp and extract the stone also could be used. Often a nephrostomy tube is left in place initially to prevent the stone fragments from passing through the normal urinary tract.
The nurse provides routine nephrostomy tube care and monitors the client for complications after the procedure. Possible complications include bleeding at the site or through the tube, pneumothorax, and infection.
Laparoscopic Ureterolithotomy. Laparoscopic ureterolithotomy uses a laparoscope to access the ureters. The surgeon enters the ureter and removes, fragments, and vaporizes the stone with the laser. Preoperative and postoperative care is the same as for any laparoscopic procedure.
OPEN SURGICAL PROCEDURES. After failed attempts to remove the stone through other methods, or when risk of a lasting injury to the ureter or kidney is possible, an open ureterolithotomy (into the ureter), pyelolithotomy (into the kidney pelvis), or nephrolithotomy (into the kidney) procedure may be indicated. These procedures are used for a large or impacted stone.
Preoperative Care. The nurse prepares the client for the selected procedure by explaining how, when, and where the procedure will be performed. The nurse describes what the client can expect before and after the procedure. The client receives nothing by mouth and also receives preoperative bowel preparation. (See Chapter 17 for routine preoperative care.)
Operative Procedures. The retroperitoneal area is entered through a large flank incision, as for nephrectomy (see Chapter 71), for pyelolithotomy or nephrolithotomy and through a lower abdominal incision for ureterolithotomy. The urinary tract is entered surgically and the stone removed. Before closure, various tubes and drains may be placed (e.g., nephrostomy tube, ureteral stent, Penrose or other wound drainage device, and Foley catheter).
Postoperative Care. The nurse follows routine procedures for assessment of the client who has received anesthesia. (See Chapter 19 for routine postoperative care.) The concerns after urologic surgery are monitoring the amount of bleeding from incisions and in the urine, maintaining adequate urine output, straining the urine to monitor the elimination of stone fragments, and assisting the client in preventing future stones through dietary modification.
INFECTION PREVENTION. Control of infections before invasive and noninvasive procedures is critical for the prevention of urosepsis. Interventions include the administration of appropriate antibiotics, either to eliminate an existing infection or to prevent new infections, and the maintenance of adequate nutrition and fluid intake. Because infection is always a component of struvite stone formation, the health care team plans for long-term prevention.
DRUG THERAPY. The clinician initially prescribes broad-spectrum antibiotics, such as the aminoglycosides (e.g., gentamicin [Garamycin]) and cephalosporins (e.g., cephalexin [Keflex, Novo-Lexin1*1]), for treatment of infections occurring with urologic stone disease. The broad coverage is effective against gram-negative bacilli. After the results of the culture and sensitivity (C&S) studies are obtained, the clinician can select more specific antibiotics. C&S studies may be done 48 hours after the initiation of antibiotic therapy and again 48 hours after the conclusion of the prescribed course of therapy.
Blood levels of certain antibiotics, such as the aminoglycosides, are measured to ensure that appropriate levels of the antibiotic have been reached. If the desired blood level of these antibiotics is exceeded, toxic effects and kidney damage may result. If the blood level of the antibiotic is inadequate, microorganisms may not be completely eliminated. New clinical evidence of an infection (such as chills, fever, or altered mental status) warrants the collection of a urine sample for repeated C&S tests.
For the client with struvite stones, the primary care provider prescribes periodic and long-term monitoring of the urine for infection. Commonly, urine cultures are ordered monthly for 3 months, then quarterly for 1 year. Drugs that prevent bacteria from splitting urea, such as acetohydroxamic acid (Lithostat) and hydroxyurea (Hydrea), are often prescribed on a long-term basis for clients with struvite stones. The primary care provider monitors the serum creatinine with acetohydroxamic acid; its administration is contraindicated for levels above 2 mg/dL. The nurse reviews interventions aimed at preventing urinary tract infection (UTI) (see Interventions [Cystitis], p. 1618).
DIET THERAPY. The client's diet ideally includes adequate calorie intake representing a balance of all food groups. Unless medically contraindicated, the nurse encourages fluid intake of 2 to 3 L/day.
PREVENTION OF OBSTRUCTION. Measures to prevent urinary obstruction by stones include a high intake of fluids (3 L/day or more) and careful measures of intake and output. A liberal but not excessive fluid intake assists in preventing dehydration, promotes the flow of urine, and decreases the chance of crystals forming a stone. Interventions also depend on the type of stone. Medications, diet modification, and fluid intake are the major strategies available.
DRUG THERAPY. The selection of drugs for the prevention of obstruction depends on what is promoting the formation of stones and the type of stone formed. The nurse teaches the client the reason for the medication and assesses for side effects or adverse drug reactions.
CALCIUM-CONTAINING STONES. Drugs to treat hyper-calciuria (high levels of calcium in the urine) may include thi-azide diuretics (e.g., chlorothiazide [Diuril] or hydrochloro-thi-azide [HydroDiuril, Natrimax^, Urozide^]), orthophosphate, and sodium cellulose phosphate. The thiazide diuretics promote calcium resorption from the renal tubules back into the body, thereby preventing excess calcium loads in the urine. Orthophosphate affects normal calcium-phosphorus metabolism, resulting in decreased urinary saturation of calcium oxalate. Sodium cellulose phosphate reduces intestinal absorption of calcium.
OXALATE-CONTAINING STONES. For clients with hy-peroxaluria (high levels of oxalic acid in the urine), allopurinol (Zyloprim) and vitamin B6 (pyridoxine) are used.
URIC ACID-CONTAINING STONES. For clients with chronic gout, allopurinol helps prevent the formation of urate (uric acid) stones. To alkalinize the urine, medications such as potassium citrate, 50% sodium citrate, and sodium bicarbonate may be used. The desired urinary pH is 6 to 6.5. Because the normal urinary pH averages 5 to 6, these desired values are termed "alkaline."
CYSTINE-CONTAINING STONES. For clients with cystinuria (high levels of cystine in the urine), alpha-mercaptopropionylglycine (AMPG) and captopril (Capoten) have both been found to lower urinary cystine levels. Their use is reserved for when hydration and alkalinization of the urine have not been successful.
DIET THERAPY. Diet modification depends on the type of stone formed (Table 70-6). The nurse consults the dietitian to plan the appropriate diet for the client.
OTHER MEASURES. The nurse encourages the client to ambulate frequently. Ambulation promotes passage of stones and reduces the possibility of calcium resorption from the bones. The nurse checks the pH of the urine daily and strains the urine with filter paper to collect passed fragments of stones.
HEALTH TEACHING. Key points of health teaching are described in Chart 70-12. The client often experiences tremendous anxiety and fear that a stone and its related pain may recur. In addition to anxiety about the pain, the possibility of repeated surgical interventions or permanent and serious kidney damage is of tremendous concern. Psychosocial preparation is generally enhanced when clients know what to expect and what actions to take should the unexpected develop. The nurse reassures the client that preventive and health promotion activities are designed to prevent recurrence.
Urothelial cancers are malignant tumors of the urothelium, which is the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, and urethra. Most urothelial tumors occur in the urinary bladder. Consequently, the general term bladder cancer is sometimes used to describe this pathologic condition.
Urothelial tumors are generally low grade, have multiple points of origin (multifocal), and are recurrent. Once the tumors spread beyond the transitional cell layer, they tend to be highly invasive and metastatic. Because of the multifocal, recurrent nature of the disease, clients with superficial tumors may experience recurrence up to 10 years after being tumor free.
whereas carcinoma in situ (CIS), or stage TIS, is generally treated with excision plus intravesical (inside the bladder) chemotherapy. Disease that has spread beyond CIS is treated with more extensive resection, often a radical cys-tectomy (removal of the bladder and surrounding tissue) with urinary diversion. Chemotherapy and radiotherapy are used in addition to surgery. When the tumor remains unchecked, it can invade surrounding structures, metasta-size to distant sites (liver, lung, and bone), and ultimately lead to death.
Exposure to environmental toxins, particularly the chemicals used in the rubber, paint, electric cable, and textile industries, is highly associated with bladder cancer. The greatest risk factor for bladder cancer is tobacco use. Other risks include Schistosoma haematobium (a parasite) infection, excessive use of phenacetin compounds, and long-term administration of cyclophosphamide (Cytoxan, Procytox^).
There are approximately 54,300 new cases of bladder
cancer diagnosed each year in the
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The nurse inquires about the client's perception of general health. The gender and age of the client are documented. The nurse inquires about active and passive exposure to cigarette smoke. To detect potentially harmful environmental agents, the nurse asks the client to describe his or her occupation in detail. He or she is also asked to describe any change in the color, frequency, or amount of urine and any abdominal discomfort.
The overall appearance of the client is observed, especially skin color and general nutritional status. The nurse inspects, percusses, and palpates the abdomen for asymmetry, tenderness, and bladder distention.
The urine is examined for color and clarity. Hematuria is the predominant sign associated with bladder cancer; it may be gross or microscopic and is usually painless and intermittent. Dysuria, frequency, and urgency are usual symptoms when infection or obstruction is also present.
The nurse assesses the client's emotions, including his or her response to known or suspected bladder cancer, and notes anxiety, fear, sadness, anger, or guilt. Early symptoms are painless, and many clients ignore hematuria because it is intermittent. Clients also may be reluctant to seek treatment because they suspect a sexually transmitted disease (STD). Consequently, they may experience guilt or anger about their own delays in seeking medical attention.
The nurse assesses the client's personal methods of coping and the degree of evident support from family or significant others. Social interaction and active role relationships with others may provide support and motivation for coping with convalescence.
The only significant finding on a routine urinalysis is generally gross or microscopic hematuria. Cytologic testing on voided urine specimens is not usually helpful. Bladder-wash specimens and bladder biopsies are the most sensitive and specific tests for cancer.
Cystoscopy with retrograde pyelography is the primary method for evaluation of painless hematuria. A closed biopsy of a visible bladder tumor can be performed during cystoscopy. This is essential for staging and is usually performed in a day-surgery unit before admission to the hospital for treatment. Excretory urography is useful in identifying obstructions, especially at the ureterovesical junction. The computed tomography (CT) scan shows tumor invasion of surrounding tissues.
Ultrasonography shows masses but is less valuable for tumor staging. Magnetic resonance imaging (MRI) may help in the assessment of deep, invasive tumors.
Therapy for the client with bladder cancer usually begins with surgical removal of the tumors for diagnosis and staging of disease. For tumors extending beyond the mucosa, surgery is followed by intravesical chemotherapy or immunotherapy. High-grade or recurrent tumors are treated with more radical surgery plus intravesical chemotherapy and/or radiotherapy. Systemic chemotherapy is reserved for clients with distant metastases. (See Chapter 25 for general care of the client receiving chemotherapy or radiation therapy.)
NONSURGICAL MANAGEMENT. Prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guerin (BCG), a compound used to vaccinate against tuberculosis in some countries, is used to prevent tumor recurrence of superficial cancers (stage Tt or lower). This procedure has been more effective than single-agent chemotherapy; side effects, however, are comparable.
Multiagent systemic chemotherapy is successful in prolonging life after distant metastasis has occurred but is rarely curative. Radiation therapy has also been successful in prolonging life.
SURGICAL MANAGEMENT. The type of surgery for bladder cancer depends on the type and stage of the cancer and the client's general health status. Complete cystectomy with extensive surgical removal of surrounding muscle and tissue offers the best chance of a cure for large, invasive bladder cancers.
PREOPERAT1VE CARE. Specific client education depends on the type and extent of the planned surgical procedure. The nurse coordinates preoperative education with the physician and enterostomal (ET) therapist. The nurse discusses the type of urinary diversion and the selection of a site for the stoma. The goal is for the client to have a positive attitude about body image and a positive self-image. The nurse intervenes with educational counseling to ensure accurate understanding about self-care practices, methods of pouching, control of urine drainage, and minimization of odor.
The site selected for the stoma should be visible and avoid folds of skin, bones, and scar tissue. When possible, the client's waistline or belt area is avoided. The nurse prepares the client for the number and type of drains that will be present postop-eratively. General preoperative care is discussed in Chapter 17.
OPERATIVE PROCEDURES. Transurethral resection of the bladder tumor (TURBT) or partial cystectomy is performed for small, early, superficial tumors. In a partial (seg-mental) cystectomy, a portion of the urinary bladder is removed. This procedure is generally used when there is only a single isolated bladder tumor.
When the entire bladder must be removed (complete cystectomy), the ureters are diverted into a collecting reservoir. Techniques for urinary diversion are illustrated in Figure 70-3. With an ileal conduit, the ureters are surgically implanted in a portion of the ileum, and urine is collected in a pouch on the skin around the stoma. Increasingly, continent reservoirs are being used. With cutaneous ureterostomy or ureteroureteros-tomy, the ureter opening is brought out onto the skin. The cutaneous ureterostomies may be located on either side of the abdomen or side by side.
POSTOPERATIVE CARE. After cutaneous ureterostomy, as with the ileal conduit, an external pouch covers the ostomy to collect urine. The nurse collaborates with the enterostomal therapist and focuses care on the wound, the skin, and urinary drainage. (See Chapters 56 and 57 for ostomy care.)
The client with a Kock's pouch, a continent reservoir, may have a Penrose drain and a plastic Medena catheter in the stoma. The drain removes lymphatic fluid or other secretions; the catheter ensures urine drainage so that suture lines may heal. The physician orders irrigation of the catheter to ensure patency. General postoperative care is discussed in Chapter 19.
The nurse educates the client and family or significant others about medications, diet and fluid therapy, the use of external pouching systems, and the technique for catheterization of a continent reservoir.
With some procedures, the client may require electrolyte replacements to prevent long-term deficits. The nurse instructs the client to avoid foods that are known to produce gas if the urinary diversion uses the gastrointestinal (GI) tract. When the intestinal production of gas is minimized, flatus will not result in incontinence.
The nurse also instructs the client and family or significant others about any changes in self-care activities related to the urinary diversion. In conjunction and collaboration with the enterostomal therapist, the nurse demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms. If a Kock's pouch has been created, the client is instructed about the technique of catheterization. For all instruction, the nurse observes at least one return demonstration by the client or the family caregiver. The client ideally assumes responsibility for self-care before discharge.
The nurse assists the client in preparing psychologically for the impact of urinary diversion on self-image, body image, sexual functioning, and self-esteem. Counseling provides information and support so that the feelings of powerlessness may be minimized.
Through discussions with the client about usual social situations, the nurse helps the client gain control over new toileting practices. Men with a urinary diversion into the sig-moid colon need to learn a new habit of sitting to urinate. For clients of either gender, the nurse promotes confidence in social situations by encouraging frequent emptying of urinary collection devices before traveling or attending social functions or events. Resumption of sexual activity is a major concern for many adult clients, regardless of age; this topic needs to be addressed openly and with sensitivity. Cystectomy causes physiologic impotence in men, but treatment is available (see Chapter 76).
HEALTH CARE RESOURCES
The United Ostomy Association and the American Cancer Society units and chapters have educational materials that may be useful to clients. In some areas, local support groups have meetings to assist others and to send visitors to provide peer counseling and support. Home care personnel may assist with follow-up, easing the transition from hospital to home. The Wound, Ostomy, and Continence Nurses Society provides educational programs and a journal devoted to the care of clients with ostomies.
Bladder trauma can be caused by penetrating or blunt injury to the lower abdomen. Penetrating lower abdominal injury may occur by stabbing, gunshot wound, or other trauma in which objects pierce the abdominal wall. A fractured pelvis with puncture of the bladder by bone fragments is the most common cause of bladder trauma. Bladder trauma may also be a result of sexual assault.
Blunt trauma compresses the abdominal wall and the bladder. A seat belt may compress the bladder hard enough to cause injury, especially if the bladder is full or distended.
Clients with a penetrating bladder wound often have anuria or hematuria. In the emergency department, initial assessment includes inspection of the urinary meatus for blood.
Diagnostic tests include cystography and voiding cys-tourethrography (VCUG). If renal or ureteral trauma is suspected, IV urography is scheduled before cystography so that any leakage of bladder contrast medium does not mask the outlines of the kidneys or ureters. The cystogram shows whether there is a defect in bladder filling; the voiding cys-tourethrogram defines bladder emptying.
Bladder trauma, other than a simple contusion, requires surgical intervention. Stabilization of any fractures usually precedes bladder repair. Surgical interventions include procedures to repair the anterior or posterior bladder wall and peritoneal membrane. In general, repairs of the bladder are accomplished by closure procedures.
The client with an anterior bladder wall injury commonly has a Penrose drain and a Foley catheter in place postopera-tively; the client with a posterior bladder wall injury has a Penrose drain and Foley or suprapubic catheter. In some instances, vaginal or rectal fistulas may also require repair.
Psychosocial support is critical for clients who have sustained traumatic injuries. The nurse refers the client to appropriate resources to assist in dealing with potential psychosocial issues.