Chapter 66: Care of Patients with Urinary Problems

Priority concepts applied in this chapter are ELIMINATION, PAIN, INFECTION, and INFLAMMATION.

 The components of the urinary system are the ureters, bladder, and urethra. 
 With problems in the urinary system, homeostasis of fluids, electrolytes, nitrogenous wastes, storage
or ELIMINATION of urine, and blood pressure is disrupted. 
 Although life-threatening complications are rare, patients may have significant functional, physical,
and psychosocial changes that reduce quality of life. 
 Nursing interventions are directed toward prevention, detection, and management. 

 Bladder 
 Internal urinary Sphincter: Involuntary 
 External Urinary Sphincter: Voluntary 
 Rugae: When the bladder is empty there is a lot of folds. As the bladder fills rugae
disappear. 
 Urinary Incontinence 
 Continence is a learned behavior to control the time and place of urination and is
unique to humans and some domestic animals. 
 Efficient bladder emptying from coordination between bladder contraction and
urethral relaxation is needed for continence. 
 Not a normal part of aging
 The SNS and PNS work together to help with bladder control and storage.
Incontinence occurs any time there is a disconnect between the brain, spinal cord and
sphincters. 
 Related to: Surgery, Brain or spinal cord injury, diseases, drugs

 Incontinence is involuntary loss of urine causing social or hygienic problems. 

 stress incontinence, The most common type of incontinenceis the loss of small
amounts of urine during coughing, sneezing, jogging, or lifting. (post menopause,
obese) R/T: low estrogen levels, weak pelvic muscles
 Initial interventions: keeping a diary; behavioral interventions, such as diet
and pelvic muscle exercise; and drugs or surgery as a last resort.
 interventions: include behavior modification, psychotherapy, and electrical
stimulation devices to strengthen urethral contractions.
 may be corrected by vaginal, abdominal, or retropubic surgeries with
varying success rates.
 MEDS: estrogen for moisture and flexibility 
 Urge incontinence is the perception of an urgent need to urinate as a result of bladder
contractions regardless of the urine volume in the bladder. R/T exposure to caffeine
and nicotine because the irritate the bladder. Decrease fluid intake in the evening
hours. (Urge aka erected bladder)
 Interventions: include behavioral interventions and drugs; surgery is not
recommended.
 MEDS: anticholinergics
  Mixed incontinence, the presence of more than one type of incontinence, is more
common in older women. 
 Overflow/reflex: incontinence occurs when the bladder has reached its maximum
capacity and some urine must leak out to prevent bladder rupture. Most common in
males (BPH) (reflex caused by brain tumor)
 Interventions for the patient with reflex or overflow incontinence caused
by obstruction of the bladder outlet may include surgery to relieve the
obstruction.

 Functional Incontinence caused by factors other than disease of the lower Urinary T.
common in PT’s with Dementia 
 Causes of functional or chronic intractable incontinence vary greatly, so
the focus of intervention is treatment of reversible causes.
 Other interventions
o MEDS: Generally used for incontinence: TCA’s, Alpha Adrenergic Blockers,
Beta 3 Blockers, 
o Training: 
 Bladder Training: PT who are alert, teaching them to void at certain
intervals 
 Habit training: PT’s who are confused, you can’t teach them, so you help
them instead Scheduled toileting times. 
o Strengthening Pelvic Muscles 
 Kegel Exercises: Tighten pelvic muscles for a count and then relax takes
weeks to notice improvement
 Pessary: Small divice helps to reposition the pelvic organs something that
is worn inside 
 Cone Therapy: Weighted cones you wear for 15 min 2x day then move to
heavier cone 
 Surgery as a last resort 

 The Goal with incontinence is to prevent or stop that leakage, stop skin breakdown, odder
control. 
 Assess the abdomen to estimate bladder fullness, to rule out palpable hard stool, and to
evaluate bowel sounds. 
 With a physician’s order, determine the amount of residual urine by portable ultrasound
or catheterizing the patient immediately after voiding. 
 In women, inspect external genitalia to determine whether there is apparent urethral or
uterine prolapse, cystocele, or rectocele with pelvic floor muscle weakness. 
 Imaging is rarely needed unless surgery is being considered. 

 Urinary Tract Infection 

 Infections of the lower urinary tract and kidneys are common, especially among women
(50% of Women in her life time)
 Urinary tract INFECTION (UTI) is the most common health care–associated INFECTION. 
 UTIs are described by their location in the tract. 
  Acute infections in the lower urinary tract include urethritis, cystitis, and prostatitis,
while acute pyelonephritis is an upper urinary tract infection. 
 The site of INFECTION and type of bacteria or other organism determines treatment. 
 Care with catheters 

Cystitis: Lower Urinary Tract Infection (bladder)

 Cystitis is an INFLAMMATION of the bladder. Common causes are irritation or INFECTION

from bacteria, viruses, fungi, or parasites.
o Symptoms: Frequency, urgency, and dysuria are the common manifestations of a
urinary tract INFECTION, but cloudy, foul-smelling, or blood-tinged urine may
occur. 
o Urinate in small volumes and pain in super-pubic area 

 Women: age lose estrogen decreases moisture leads to dryness cracks and tears that
cause infection
 Elderly &UTI: Affects mental status (delirium) more prone to falls and confusion. 

 Noninfectious cystitis is caused by irritation from chemicals or radiation. 

 Interstitial cystitis is an inflammatory disease that has no known cause. 
 Infectious cystitis can lead to complications, including pyelonephritis and sepsis. 
 The diagnosis of cystitis is based on history, physical examination, and laboratory
data. 
 Urography, abdominal ultrasonography, or computed tomography may be needed to
locate the site of an obstruction or the presence of calculi. 
 Laboratory assessment for a UTI is a urinalysis performed on a clean-catch
midstream specimen with testing for leukocyte esterase and nitrate. 
 A urine culture confirms the type of organism and the number of colonies and is
indicated when the UTI is complicated or does not respond to usual therapy. 
 Catheters are the most common factor placing patients at risk for UTIs in hospital and
long-term care settings. 
 Drugs used to treat bacteriuria and promote patient comfort include urinary
antiseptics or antibiotics, analgesics, and antispasmodics. 
 Changes in fluid intake patterns, urinary ELIMINATION patterns, and hygiene patterns
can 

Pyelonephritis: Upper urinary tract infection (kidneys)

 Symptoms: More systemic, fever, nausea, vomiting, flank pain

 Can cause urosepsis if it spreads to blood stream
 Assess: Urinary analysis, WBC (leukocytes), RBC (erythrocytes), nitrites (bacteria) an
infection would be over 100,000

Treatment: Antibiotics (culture &sensitivity first)

 Meds:
 o Trimethoprim Bactrim ( sulfa drug): ask about allergies, Drink 3 L/day because it
can form crystals
o Ciprofloxin Antibiotics, Amoxicillin
o Phenazopyridine Prodium (Analgesic): orange urine
o Antispasmodics to control bladder spasms

Urethritis

 Urethritis is an INFLAMMATION of the urethra that causes symptoms similar to UTI.

 In men, manifestations of urethritis are burning or difficulty with urination and a discharge from the
urethral meatus, usually caused by sexually transmitted diseases (STDs).
 In women, urethritis causes manifestations similar to those of bacterial cystitis.
 STDs and INFECTION are treated with antibiotic therapy.
 NONINFECTIOUS DISORDERS
 Urethral Strictures
 Urethral strictures are narrowed areas that are idiopathic or caused by an STD or result from trauma
during catheterization, urologic procedures, or childbirth.
 The most common symptom of urethral stricture is obstruction of urine flow.
 Treatment includes surgery to dilate the urethra, placement of a stent, or urethroplasty. 

 Urolithiasis 
 Urolithiasis is the presence of calculi or stones in the urinary tract. 
 Stones often do not cause symptoms until they pass into the lower urinary tract, where
they can cause excruciating PAIN. 
 Commonly found in the Kidneys. Nephrolithiasis is stones in the kidney and
ureterolithiasis is stones in the ureter. 
 Composed of calcium mostly caused by Calcification. 
 Symptoms: Pain,
 Nutrition
 patients are encouraged to drink lots of fluids and eat lots of fruits and
vegetables, a low amount of protein, and a balanced intake of calcium, fats,
and carbohydrates. Foods high in oxalate stay away: Spinach, Okra, Beats 
 Types of stones:
 Calcium Oxalate
 Struvite
 Uric Acid: Develop more in PT with GOUT
 Cystine
 Staghorn

Assessment

 The major manifestation of stones is severe PAIN commonly called renal colic, most
intense when the stone is moving or when the ureter is obstructed. 
 Oliguria or anuria suggests obstruction, possibly at the bladder neck or urethra. 
 Urinary tract obstruction is an emergency and must be treated immediately to preserve
kidney function. 
 Stones are easily seen on x-rays of the kidneys, ureters, and bladder; IV urograms; or CT
Nursing interventions:

 focus on PAIN management and prevention of INFECTION and urinary obstruction. 

 Most patients can expel the stone without invasive procedures, depending on the
composition, size, and location of the stone. 
 Lithotripsy: also known as extracorporeal(outside-body) shock wave lithotripsy,
is the use of sound, laser, or dry shock waves to break the stone into small
fragments. 
 Helps the PT recover sooner, not as much pain as other interventions, after
you might need a stent placement, brusing and bleeding is normal after.
 Abnormal after: chills fever still can’t void call the doctor 
 Take antibiotics for this procedure 
 Minimally invasive surgical procedures include stenting, retrograde ureteroscopy,
and percutaneous ureterolithotomy and nephrolithotomy. 
 Medications: narcotics, antibiotics, relax the muscles with alpha blockers “zosins”
(a common side effect of Alpha is HYPOtention) 
 Less than 5 mm let the stone pass 
 Risk Factors 
 Urinary Stasis: urine is not moving retained in the body/ dehydration
 Genetics 
 Race: White
 Obesity
 Hydronephrosis 
 Enlargement of the kidneys caused by blockage of urine by a stone, permanent
kidney damage may occur 
 Hydroureter 
 When the stones occlude the ureter and block the flow of urine

Causes

 The higher the stone the harder to pass, causes permanent damage you need to
intervene,
 PT might have Hematuria because of trauma
 WBC elevated because of urinary stasis
 Check for what causes the narrowing of the tube

 Urothelial Cancer (Bladder Cancer& other) 

 Urothelial cancers are malignant tumors of the urothelium, the lining of

transitional cells in the kidney, renal pelvis, ureters, urethra, and mostly the
bladder. 
 Risk factors: Exposure to chemicals, Smokers inc. risks 
 Symptoms: Painless hematuria 
 Types of Tumors 
 T1: superficial and only affects inner lining of the bladder. 
 T2: Extended and invaded into the detrusor muscle 
  T3: ``
 T4: ``
 Interventions 
 Intravesical Immunotherapy (used in early detection only) prophylactic 
 BCG (live virus) is instilled into the bladder through a catheter, this helps
the body stimulate the immune system. is used to prevent tumor
recurrence of superficial cancers.
 Bladder Tumor Resection
 Excising the tumor with surgery 
 Scope through urethra into the bladder to remove tumor 

Urinary Diversion 

 Bladder might be removed if the cancer spreads 

 Four alternatives are used after cystectomy: ileal conduit, continent pouch,
bladder reconstruction (also known as neobladder), and ureterosigmoidostomy

 Conduit 
 Small part of the intestine is used urine comes out of the body
through stoma. External bag 
 Ureterostomies 
 External Bag 
 Sigmoidostomies 
 Reconstructed ureters connected to large intestine urine comes out
with bowel movements. No Bag 
 Ileal Reservoir 
 Pouch and stoma continent and PT remove urine with a catheter.
NO Bag 
 Observe the patient’s overall appearance, including skin and nutritional status. 
 Perform a focused assessment on the abdomen, bladder, and urine. 
 Dysuria, frequency, and urgency occur when INFECTION or obstruction is also
present. 
 The only significant finding on a routine urinalysis is gross or microscopic hematuria. 
 Cystoscopy with retrograde urography is usually performed to evaluate painless
hematuria, and a biopsy of a visible bladder tumor can be performed. 
 Therapy for the patient with bladder cancer usually begins with surgical removal of the
tumors for diagnosis and staging of disease. 

 Tumors confined to the bladder mucosa are treated by simple excision, whereas those that
are deeper but not into the muscle layer are treated with excision plus intravesical
chemotherapy. 
 Complete bladder removal with additional removal of surrounding muscle and tissue
offers the best chance of a cure for large, invasive bladder cancers. 
 Chemotherapy and radiation therapy are used in addition to surgery. 
 Assess the patient’s coping methods and available support from family members. Social
support may provide motivation and improve coping during recovery from treatment. 
 Bladder Trauma 

 Bladder trauma can be caused by penetrating or blunt injury to the lower

abdomen. 
 Penetrating injury may occur by stabbing, gunshot wound, or other trauma in
which objects pierce the abdominal wall. 
 Blunt trauma compresses the abdominal wall and the bladder. 
 Bladder trauma, other than a simple contusion, requires surgical intervention. 
 Psychosocial support is critical for patients who have sustained traumatic injuries.
Refer them to counseling resources to assist in dealing with psychosocial issues. 

GENERAL GUIDELINES WHEN CARING FOR PATIENTS WITH URINARY PROBLEMS 

 Use sterile technique when inserting a catheter or any other instrument. 

 Use Contact Precautions with drainage from the genitourinary tract. 
 To prevent INFECTION, teach patients to clean the perineal area after voiding, after having a bowel
movement, or after sexual intercourse. 
 Encourage all patients to maintain an adequate fluid intake, a minimum of 1.5 to 2.5 L daily, unless
another health problem requires fluid restriction. 
 Instruct women who have stress incontinence in the proper way to perform pelvic floor strengthening
exercises. 
 Teach patients who come into contact with chemicals in their workplaces or with leisure- time
activities to avoid direct skin or mucous membrane contact. 
 Use a nonjudgmental approach in caring for patients with urinary incontinence. 
 Avoid referring to protective pads or pants as “diapers.” 
 Recognize the need for the patient undergoing cystectomy and urinary diversion to grieve about the
body image change. 
 Assess comfort in discussing issues related to elimination and the urogenital area. 
 Use language and terminology that patients are comfortable with during assessment. 
 Report immediately any condition that obstructs urine flow. 
 Instruct patients with UTI to complete all prescribed antibiotic therapies even when symptoms of
infection are absent.
Evaluate daily the indications for maintaining indwelling catheters and discontinue their use as soon
as possible. 
 Teach patients the expected side effects and adverse reactions to prescribed drugs. 
 Assess the patient’s manual dexterity and cognitive awareness before teaching a regimen of
intermittent self-catheterization. 