1. INTRODUCTION

2. Urinary tract infections (UTIs) are the infections caused by pathogenic microorganisms in the urinary tract with or without signs and symptoms lower urinary symptoms may predominate at the bladder or urethra DEFINITION 3. infections involving the upper urinary truct acute or chronic pyelonephritis (inflammation of the renal pelvis) interstitial nephritis (inflammation of the kidney) renal abscesses CLASSIFICATION 4. bacterial cystitis (inflammation of the urinary bladder) bacterial prostatitis (inflammation of the prostate gland), bacterial urethritis (inflammation of the urethra). infections lower urinary tract 5. uncomplicated community acquired complicated, occurs in people with urologic abnormalities occurs due to recent catheterisation nosocomial Other classifications are 6. pyelonephritis -inflammation of renal parenchyma cystitis - inflammation of bladder wall urethritis - inflammation of urethra urosepsis -UTI spread into systemic circulation ANOTHER CLASSIFICATION 7. The incidence rises to 50% in women over the age of 80 UTI is one of the most common reasons patients seek healthcare. Most cases occur in women, with one of every five women INCIDENCE 8. Epidemiologically, UTIs are subdivided into catheter associated(or nosocomial) infections and non- catheter-associate(orcommunity acquired)infection symptomatic or asymptomatic EPIDEMIOLOGY 9. gram-negative bacilli Escherichiacoli causes 80% of acute infections in patients without catheters,urologic abnormalities, or calculi. Other gram-negative rods, Proteus and Klebsiella and occasionally Enterobacter,staphylococcus aureus,shigella ,proteus ETIOLOGY 10. the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes antibodies, anti adherent effects mediated by the mucosal cells mechanisms maintain the sterility of the bladder 11. For infection to occur, bacteria must gain access to the bladder, attach to it and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defence mechanisms, and initiate inflammation. Most UTIs result from focal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces Pathophysiology 12. increasing the normal slow shedding of bladder epithelial cells Glycosaminoglycan (GAG) The normal bacterial flora of the vagina and urethra Urinary immunoglobulin (IgA) Defences against BACTERIAL INVASION OF THE URINARY TRACT 13. Urethrovesicalreflux- which is the reflux (backward flow) of urine from the urethra into the bladder With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, REFLUX 14. Bacteriuria is generally defined as more than 105 colonies of bacteria per millilitre of urine. Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding105 colonies/mL of clean-catch midstream urine is the measure that distinguishes true bacteriuria from contamination. In men, contamination of the collected urine sample occurs less frequently; hence, bacteriuria can be defined as 104 colonies/mL urine UROPATHOGENIC BACTERIA 15. Infection can ascend up the urethra (ascending infection), through the blood stream, (haematogenous spread), By means of a fistula colonize the periurethral area and subsequently enter the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uro pathogenic bacteria. Sexual intercourse . (haematogenous spread) from a distant site of infection through direct extension by way of a fistula from the intestinal ROUTES OF INFECTION 16. no symptoms. pain at the urethra burning on urination, frequency, urgency nocturia,incontinence suprapubic or pelvic pain. Hematuria and back pain may also be present. In older individuals, these typical symptoms are seldom noticed Signs and symptoms of upper UTI (pyelonephritis) include fever, chills, flank or low back pain, nausea and vomiting, headache, malaise, and painful urination. Clinical Manifestations 17. Physical examination pain and tenderness in the area of the costovertebral angles urine dipstick may react positively for blood ,white blood cells nitrates indicating infection urine microscopy shows red blood cells and many white blood cells per field without epithelial cells urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing USG and CT studies Diagnostic finding 18. A colony count of at least 105 colony-forming units (CFU) per millilitre of urine on clean-catch midstream or catheterized specimen is a major criterion for infection About one third of women with symptoms of acute infections have negative midstream COLONY COUNTS 19. Microscopic Hematuria (greater than 4 red blood cells [RBCs] per high- powerfield Pyuria (greater than 4 white blood cells [WBCs] per high-power field) CELLULAR STUDIES 20. gold standard in documenting a UTI URINE CULTURES 21. pharmacologic therapy patient education. Medical Management 22. 1. cephalosporin 2. ampicillin 3. aminoglycoside 4. trimethoprim 5. sulfamethoxazole 6. other choices are bacterim ,septrin, 7. ampicillin or amoxicillin 8. fluoroquinolone or ciprofloxacin 9. Levofloxacin 10. Ciprofloxacin and norfloxacin Commonly used antibiotics 23. Pyridium Sodabicarb power-to make urine alkaline urinary analgesic 24. In females with recurrent uti is treated with long term antibiotic prophylaxis Usually continued for 6months or more LONG-TERM PHARMACOLOGIC THERAPY 25. Assessment History Symptoms Habits Hygiene Urine assessment NURSING PROCESS 26. 1. Acute pain related to inflammation and infection of the urethra, bladder, and other urinary tract structures as evidenced by positive urine culture results 2. Deficient knowledge related to factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy NURSING DIAGNOSES 27. relieving pain monitoring and managing potential complications measures to prevent catheter associated infection promoting home and community-based care teaching patients self-care Nursing Interventions 28. Thank you 29. INTRODUCTION CANCER OF THE BLADDER 30. Anatomy and physiology 31. 1. Transitional cell (urothelial) carcinoma 2. adeno carcinoma 3. Squamous cell carcinoma 4. Sarcoma TYPES OF BLADDER CANCER 32. Non-invasive bladder cancers are still in the inner layer of cells (the transitional epithelium) but have not grown into the deeper layers. Invasive cancers grow into the lamina propria or even deeper into the muscle layer. Invasive cancers are more likely to spread and are harder to treat. Discription of bladder cancer 33. Papillary carcinomas They grow in slender, finger-like projections from the inner surface of the bladder toward the hollow center. Transitional cell carcinomas 34. Flat carcinomas They do not grow toward the hollow part of the bladder at all. If a flat tumor is only in the inner layer of bladder cells, it is known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).If either a papillary or flat tumor grows into deeper layers of the bladder, it is called an invasive transitional cell (or urothelial) carcinoma. 35. Exact etiology is unknown Cigerette smoking Exposure with chemical dyes Exposure with cytoxan Radiation therapy Chronic irritation of the bladder Excessive use of phenacetin ETIOLOGY 36. The tumour usually starts in the epithelium of the inner bladder the tumour gradualy invades the muscular layer followed by serous layer at his stage their can be local lymph node involvement the next stage is extensive local spread tumour can spread to peritoneum prostate ,or uterus in females ,patient will present with haemorrhagic symptoms and tumour related pressure effect . the next stage is distant metastasis in which tumour spreads to bones lungs ,brain etc Pathophysiology 37. Painless Hematuria ,either gross or microscopic Dysuria Frequency Urgency Pelvic flank pain Leg oedema Clinical Manifestations 38. 1. cystoscopy 2. bladder washed cytology 3. urine for flow cytometry 4. IVP 5. MRI scan 6. Chest x ray 7. excretory urography, 8. CT scan, 9. ultrasonography, 10. bimanual examination 11. Biopsies of the tumour and adjacent mucus Assessment and Diagnostic Findings 39. Urine tests for tumor markers: UroVysion: BTA tests: Immunocyt: NMP22 BladderChek: Newer diagnostic methods 40. American Joint Committee on Cancer Also called the TNM system. TNM staging system for bladder cancer 41. T category( tumour ) letter T is followed by numbers and/or letters to describe how far the main (primary) tumor has grown through the bladder wall and whether it has grown into nearby tissues. Higher T numbers mean more extensive growth. 42. N category( node ) The letter N is followed by a number from 0 to 3 to indicate any cancer spread to lymph nodes near the bladder. Lymph nodes are bean-sized collections of immune system cells, to which cancers often spread first. 43. M category (metastasis) The letter M is followed by 0 or 1 to indicate whether or not the cancer has spread (metastasized) to distant sites, such as other organs or lymph nodes that are not near the bladder. 44. Has minimal role, concentrates on symptom management and supportive in nature Treatment of bladder cancer depends on the grade of the tumour Medical Management 45. cystoscopy bladder washed cytology urine for flow cytometry IVP MRI scan Chest x ray excretory urography, CT scan, ultrasonography, bimanual examination Biopsies of the tumour and adjacent mucus Assessment and Diagnostic Findings 46. Transurethral resection with fulguration (electrocautery) Laser photocoagulation Open loop resection Segmental cystectomy Partial cystectomy Radical cystectomy SURGICAL MANAGEMENT 47. methotrexate, 5 fluorouracil,vinblastine, doxorubicin (Adriamycin), and cisplatin gemcitabine and the taxanes Topical chemotherapy-thiotepa, doxorubicin mitomycin, ethoglucid, and BCG) to the tumor to promote tumor destruction. PHARMACOLOGIC THERAPY 48. Radiation of the tumour may be performed preoperatively to reduce micro extension of the neoplasm and viability of tumour cells thus reducing the chances that the cancer may recur in the immediate area or spread through the circulatory or lymphatic systems RADIATION THERAPY 49. External beam radiation Intensity modulated radiotherapy Brachytherapy Types 50. The use of photodynamic techniques in treating superficial bladder cancer is under investigation. This procedure involves systemic injection of a photosensitizing material (hematoporphyrin), which the cancer cell picks up. A laser-generated light then changes the hematoporphyrin in the cancer cell into a toxic medication. This process is being investigated for patients in whom Intravesicalchemotherapy or immunotherapy has failed INVESTIGATIONAL THERAPY 51. Ileal Conduit (Ileal Loop) The Ileal conduit, the oldest of the urinary diversion procedures ,is considered the gold standard because of the low number of complications and surgeons familiarity with the procedure. In an Ileal conduit, the urine is diverted by implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall Utreostomy Directing ureters into skin Nephrostomy Urine to drainage bag directly through a catheter URINARY DIVERSIONS 52. Continent Ileal Urinary Reservoir (Indiana Pouch) The most common continent urinary diversion is the Indiana pouch, created for patients whose bladder is removed or can no longer function (neurogenic bladder). The Indiana pouch uses a segment of the ileum and cecum to form the reservoir for urine The ureters are tunnelled through the muscular bands of the intestinal pouch and anastomosed. The reservoir is made continent by narrowing the dfferent portion of the ileum and sewing the terminal ileum to the subcutaneous tissue, forming a continent stoma flush with the skin. The pouch is sewn to the anterior abdominal wall around a cecostomy tube. Urine can collect in the pouch until a catheter is inserted and the urine is drained. CONTINENT URINARY DIVERSIONS 53. Ureterosigmoidostomy, another form of continent urinary diversion, is an implantation of the ureters into the sigmoid colon It is usually performed in patients who have had extensive pelvic irradiation, previous small bowel resection, or coexisting small bowel disease. Ureterosigmoidostomy 54. Anxiety related to anticipated losses associated with the surgical procedure Imbalanced nutrition, less than body requirements related to inadequate nutritional intake Deficient knowledge about the surgical procedure and postoperative care Preoperative Nursing Diagnoses 55. RELIEVING ANXIETY ENSURING ADEQUATE NUTRITION EXPLAINING SURGERY AND ITS EFFECTS Interventions 56. MAINTAINING PERISTOMAL SKIN INTEGRITY RELIEVING PAIN IMPROVING BODY IMAGE EXPLORING SEXUALITY ISSUES MONITORING AND MANAGING POTENTIAL COMPLICATIONS Postoperative Nursing Interventions 57. Peritonitis Stomal Ischemia and Necrosis Stomal Retraction and Separation Complications 58. Continuing Care Teaching Patients Self- Care 59. Evidence based practice 60. Conclusion 61. BIBLIOGRAPHY 62. Thank you