Elimination and Cellular Regulation Flashcards
- process of urinary and gastrointestinal elimination.
- elimination refers to the secretion and excretion of body wastes from the kidneys and intestines and any alterations from normal of those process.
- Pre-renal, Renal and Post-Renal.
Elimination
dehydrated, problem with electrolytes
Pre-renal
issue with the kidney itself
Renal
kidneys are fine, but something is effecting or blocking
Post renal
Presence of calculi (stones) in the urinary tract
- nephrolithiasis; formation of stones in the kidney
- Urterolithiasis; formation of stones in the ureter
*Obstruction of the urinary tract is the primary problem associated with urolithiasis.
Urinary calculi-Kidney stone
Painful!
Movement of multifaceted crystal that scrapes the ureter as it moves.
-“most painful experience” of the person’s life.
-Most common cause of upper urinary tract obstruction.
flank pain and around the front external genitalia
Kidney stones
-Slow urine flow causing supersaturation with a particular element
-Nucleation-Formation of crystal from liquid.
-Decreased inhibitor substances in the urine that would prevent supersaturation and crystal aggregation.
(People that get them don’t have inhibitor substance)
Formation of stones involve 3 conditions.
2.5 x more common in Males than females between 20-55 yrs of age.
-50% can expect a recurrence
-Family hx
-More common in Asians and whites
More common in dry climates, summer time due to dehydration.
Epidemiology
Calicum oxylate or Calcium Phosphate 75% *most Ca stones
~Struvite/Staghorn 15%; Assoc with UTI caused by Urease-production bacteria such as Proteus.
~Uric Acid 8%; Occur more often in men and associated with Gout; build up of uric acid in joints and gets inflammed
~Cystine 3%; Assoc with genetic defect.
Types of Stones
Urinary stasis, Urinary retention
- immobility
- dehydration/inadequate hydration
- high protein and sodium intake
- Hypercalciuria, Hypercalcemia; calcium in urine or blood
- Hyperparathyroidism
- prolonged steroid intake. Steroids steal Ca from bones
- Genomics; 30 genetic variations assoc with formation of kidney stones.
Contributors to Stone Formation
Acute severe flank pain on the affected side.
-stone obstructs the ureter causing ureteral spasm.
-Pain may radiate to the suprapubic region, groin and external genital.
Often causes a sympathetic response; tachycardia fight or flight response.
N and V. pallor, cool clammy skin
-Stones traumatize ureter causing microscopic to gross hematuria; little/lot of blood
-Complete blockage; hydroureter, Hydronephrosis………..Post renal become renal if not corrected.
Renal Colic
- Mg ammonium phosphate
- Caused by bacteria usually Proteus
- Raising the urinary pH which favors precipitation; alkaline urine, stones to form
- higher incidence in women.
Staghorn/struvite Calculi
Relieve pain by administering drugs
-Eliminate the stones through chemolysis, ESWL (Shock wave), or surgery to remove stones.
-Prevent recurrence by dietary changes, medications and changing the pH of urine.
Fluids, fluids fluids
3 goals of medical management for kidney stones
Administer narcotic analgesics and antispasmodics
- Morphine, Demerol, Dilaudid;(drug of choice for kidney issue)
- NSAID-Toradol (ketorolac)
- hold Nsaid, ASA (aspirin) if surgery is likely bc of increased bleeding risk.
- Apply warm moist packs or offer warm baths.
- Increase fluid intake to at least 3000 ml/day
- Strain all urine-Send stones to lab to find out what type they are. food to avoid, different meds to help. Acidifying or alkaline stone
Nursing Actions for kidney stones
- Urinalysis to assess for hematuria, WBC’s, crystal fragments, Urine pH.
- Chemical analysis of stone-All urine is strained and visible stones or sediment sent for analysis.
- Urine is analyzed for Uric Acid, oxylate excretion.
- KUB; kidney Ureter Bladder Film
- Renal Ultrasound
- CT Scan; gold standard identification
- IV Pyelogram-Dye injected (Beware of dye/seafood allergy) renal; creatinine worsen kidney issues with dye
- Cystoscopy; invasive; bladder; urether
Diagnostic Testing
Minimally Invasive;
- Stenting-enlarges passageway for stone to pass
- Retrograde ureteroscopy, -scope has grasping basket forceps or loops;
- Ureteroscope may be lithotripsy capable; shock waves to the stone.
Surgical Management
Minimally Invasive
Uses sound, laser or dry shock waves to break stone into small fragments. fragmenting kidney stones by using major surgery.
-Shock waves are applied over 30 mins to 2 hours. outside the body.
-Topical cream applied to skin; external, skin can get nasty bruises.
-Bowel prep may be requested.
-Flouroscopic observation for stone destruction during procedure *radiation
-Strain urine to monitor for stone fragments
-Bruising may occur on flank at site of procedure; may be extensive.
Cystine stones usually resistant to ESWL. strong stones
Lithotripsy; Extracorporeal shock wave lithotripsy (ESWL); noninvasive technique
Monitor VS frequently
-Hemorrhage and shock are potential complications; hypovolemic shock
-Bleeding may be retroperitoneal and internal and difficult to detect. c/o low back pain, bleeding H & H lab, stat Cat Scanurine may be bright red initially
bleeding should diminish in 48-72 hours.
Maintain placement and patency of urinary catheters. Anchor catheters securely.
-A kinked or plugged cath may result in hydroureter, hydronephrosis, and kidney damage.
Nursing Care Post-Lithotripsy
Used for large impacted stones.
-open ureterolithotomy-into the ureter (incision is made in the affected ureter to remove a calculus).
Pyelolithotomy-into the kidney pelvis (incision made in the kidney pelvis and removal of a stone).
_Nephrolithotomy; into the kidney; a staghorn calculus that invades the calyces and renal parenchyma maybe required by nephrolithotomy.
*Tubes and drains may be placed.
-Nephrostomy tube, ureteral stent, Penrose, Bulb drain, Foley catheter.
Open Surgical Procedures for Kidney stones
Monitor for bleeding from incision, blood in urine and pain suspicious for internal bleeding. Assess for Shock.
-Maintain fluid intake, monitor I & O’s, strain urine
Post-Op Care:
irrigate q shift with no more than 10 ml of warm, sterile saline.
-Observe for hemorrhage, internally or externally
kidneys are highly vascular.
INR levels
-nephroscope inserted into the kidney pelvis through a small flank incision.
Percutaneous nephrostomy PCN; laser technique
Collaborate with Dietary to give nutrition recommendations based on the type of stone.
- Drink 2.5-3.5 Liters or more a day to provide diluted urine and promote the flow of urine to decrease chance of crystals forming
- encourage activity to prevent bone reabsorption (loss)
Patient Education for kidney stones
A diet excluding foods high in oxalates, do not decrease "Calcium" Foods High in Oxalic Acid `Coffee (instant dry), and Tea brewed `Blackberries, gooseberries, plums (raw) `whole wheat bread `beets, boiled carrots, greenbeans, rhubarb, boiled spinach `cocoa (dry) `ovaltine powder
Oxalate stones and diet
Don’t limit Ca, bc it will be taken from the bone
“kidney stones are not usually caused by dietary calcium. A high-calcium diet binds the oxalate of dietary origin in the gastrointestinal tract and prevents its absorption, thereby reducing urinary oxalate formation”.
Kidney stones
Purine stones: Patients with gout are often put on medication to control gout so may not be placed on low purine diet.
Uric Acid Stones-Diet
Foods high in Purine to avoid:
- Organ meats, liver, kidney, brain, heart
- anchovies, sardines in oil, herring
- sweetbreads
- gravies
high in purine to avoid
Moderate amounts of purine:asparagus, cauliflower, mushrooms, spinach, peas
fowl, lentils, whole grain cereals, beans
moderate in purine to avoid
Oral and Iv fluids reduce the risk of further stone formation and promote urine output.
-After identification of Calculus, med given based on stone kind.
Calcium phospate and or oxalate-Thiazide diuretics, phosphates, calcium binding agents. Struvite; antibiotics
Uric Acid; Potassium Citrate, Allopurinol-akaline urine good for cystine stones, too.
`Cystine-Penicillamine, Sodium becarbonate
Stones and Pharmacology
Age Related;
Nonmalignant enlargement of the prostate gland.
-decreases the outflow of urine by obstructing the urethra causes problems with urination and may compromise kidney function
-Growth may extend up into the bladder and obstruct the outflow of urine
`Not a pre-cursor to prostate cancer!
Preconditions include Age 50 and presence of testes.
-affects 50% of men 51-60, 90% over age 80.
Benign Prostatic Hypertrophy or Hyperplasia BPH
As men age, estrogen levels increase and testosterone levels decrease.
-Elevation of the enzyme 5-alpha-reductase converts testosterone to dihydrotestosterone (DHT) which causes cells to grow. hyperplasia; increase enlarge
-DHT is an androgen hormone.
androgen stimulate the development and maintenance of male sex characteristics.
Etiology of BPH
Age
Fam hx
Race; highest in black and hispanic and lowest in Native Japanese
Diet high in meats and fats
Risk factors for BPH
-Tissue obstructs urethra and bladder outlet
-Urine flow becomes weak
-Straining to empty bladder causes hypertrophy of bladder wall.
-Trabeculation of bladder wall leads to decreased bladder capacity.
-Increased filling pressure causes back up of urine into kidney
-Hydroureters and hydronephrosis and kidney atrophy
-Residual urine becomes alkaline from Stasis.
-Promotes UTI’s and renal and bladder calculi.
-Akaline urine increases stones
Usually patient understands they got it because they lived long enough.
Pathophysiology of BPH-
- Straining to urinate
- post void dribbling
- hesitancy in starting stream
- nocturia
- dysuria
- hematuria
- urgency
- frequency
- incomplete emptying of bladder
- overflow incontinence
- bladder pain.
Clinical Manifestations of BPH
Inability to void (Emergency-What now?) catheter, cudea (bent catheter)
Frequent UTI’s (Labs?) CBC’s-WBC’s
Hematuria (Labs; blood/urinalysis)
Renal and Bladder stones (Calculi)
Renal insufficiency (Labs) BUN, Creatinine
Difficulty or inability to pass urinary catheter
Bladder distention
Bladder Pain
Clinical Manifestations; With higher degree of blockage
Common complications are kidney disorders caused by pressure and backflow of urine.
- Recurrent UTI’s
- Pyleonephritis; inflammation of above the bladder, kidneys, urethers are inflammed
- Sepsis, infected blood
- Secondary renal insufficiency
Complications
Lab tests
- CBC; eval for infection or anemia
- blood urea nitrogen (BUN), Creatinine
- urinalysis
- prostate specific antigen (PSA), baseline is good. not good for prostate cancer diagnosis anymore.
- JM-27; testing for more severe/aggressive form of BPH. More serious bladder damage leading to renal impairment.
Diagnostic Tests (BPH)
Severity of the obstruction.
Client’s condition
Catheterization is necessary for those clients experiencing acute urinary retention.
Determine initial treatment
- Reduce the size of the prostate gland:
ex. 5-alpha reductase inhibitor (5-ARI)
finasteride (Proscar)
Dutasteride (Avodart)
*****rides, antiandrogen - Relax the bladder neck to open the internal urethral sphincter.
ex. Alpha blocking agents
tamsulosin (Flomax)
doxazosin (Cardura)
prozosin (Minipress)
terazosin (Hytrin)
*****osins, relax the bladder
Both classes of drugs can cause liver problems and require follow up.
2 Goals of Medication Treatment
Finasteride (Proscar)
- inhibits activity of 5-alpha reductase so testosterone not converted into DHT reducing prostate size.
- effects may not be noticeable for up to 6 months to 1 year.
- maynot always help the symptoms of urinary retention.
- finasteride (Proscar), dutasteride (Avodart)
- Side Effects: decreased libido, impotence, and ejaculation disorders
- can interfere with PSA monitoring by lowering the PSA levels by 50%
- Med can be absorbed through the skin; Teratogenic to a male fetus.
Finasteride (Proscar) 5-alpha reductase inhibitor (5-ARI)
antihypertensive; dizziness
-used to relax muscles and reduce straining on urination
-Alpha-receptors are found in prostatic smooth muscle.
blocking these receptors constricts the prostate.
-Dilates both arteries and veins. pass the urine
-Main side effects of most of these drugs are orthostatic hypotension, and fatigue.
-Tamsulosin (Flomax), Prozosin (minipress)
Terazosin (Hytrin)
Alpha-blocking agent BPH
lycopene (tomatoes) palmetto berry the bark of Pygeum aficanum The roots of Echinacea purpurea and Hyposix rooperi leaves of trembling poplar research is ongoing.
Complementary Alternative Medicine. BPH
- Bladder irritants: Alcohol and caffeine
- Alpha adrenergic agents: Decongestants such as pseudoephedrine and phenylephrine. vasoconstrictors coldmeds
- Anticholinergics: such as antihistamines, Tricyclic antidepressants and phenothiazines.
- Testosterone and other anabolic steroids may increase prostate size. hyperplasia.
Meds and foods to avoid with BPH
Thermotherapy
- TUNA-Transurethral Needle ablation
- low radiofrequency
- TUMT-Tranurethral microwave therapy
- high temp heat destroys excess tissue.
- ILC-Interstitial laser coagulation
- laser energy
Electrovaporization
-electrical current cuts and vaporizes excess tissues.
TUIP-transurethral incision of the prostate; incision made where prostate attached to the bladder
Balloon Urethroplasty and placement of stents
BPH; therapies
Necessary to provide more permanent relief of symptoms.
Resectoscope is passed through the urethra and the gland is removed in small pieces by an electric cutting loop.
Transurethral Resection of Prostate (TURP)
No incision
Ideal for high risk clients who have small glands
Can be done with spinal anesthesia
Turp advantages
Possible complications; postop hemorrhage, clot retention, inability to void, UTI, incontinence, impotence, retrograde ejaculation, bladder perforation.
-Strictures are common
-Urethral trauma may occur
-Remaining prostate tissue may continue to grow.
May require more TURP’s
Turp disadvantages
Clotting studies.
Use of ASA, NSAIDs increases risk of peri and post op bleeding.
Teds and PCB’s
Teacing Post op expectations
-catheter; bloody urine with a few clots and tissue.
-Continous bladder irrigation. CBI
Preoperative Care
3-way Foley is inserted and inflated
-pulled down so its in the prostatic fossa to control bleeding and prevent hemorrhage.
-Will perceive urge to void
attempting to void around the catheter causes “bladder spasm”
Continuous irrigation prevents clot retention.
Usually discontinued within 24 to 48 hours
TURP
Irrigating fluid (glycine) is used during the procedure which can be absorbed through open capillaries into the bloodstream resulting in hypervolemia and dilutional hyponatremic state. deluting person with fluid.
-Assessed for in 1st 24 hrs.
-Only seen in about 2% of cases
-A medical emergency, because it may result in cerebral edema, arrhythmias and seizures.
-the longer the surgery, the greater the risk.
Monitor for low Na, H & H, bradycardia, nausea and confusion.
H &H will drop little, bot not supposed to be a lot.
Turp syndrome; Water Intoxication
Maintain patency of the catheter
-check catheter tubing first for kinks or clots
-Manual irrigation and aspiration of clots may be required. (MD order required)
-UO- q2 hr.
absence of urine output-immediate attention
misplaced catheter, clots blocking catheter
Post op Care Turp
Arterial bleeding is bright red. notify dr.
-increase CBI Rate. may need to increase traction on catheter.
Monitor VS to assess for hypovolemic shock.
Venous bleeding is darker red/burgundy
-red/pink, changing to light pink in 24 hrs
-a color change from pink to amber indicates a decrease in bleeding
-Strict I & O’s
Post op Turp
Strict I & O’s
Output should be 50cc/hr>hourly flow of irrigation solution
Assure an adequate intake of at least 1500-2000/25 hrs
Assess for s/s of water intoxication (hyponatremia)
-confusion, nausea
-increased bp, decreased pulse
Monitor H & H
-increase monitoring required based on amount of bleeding.
Post operative care for TURP
irritability can cause bleeding. Traction on catheter can increase spasm.
Give antispasmodics
-Belladonna and opium (B and O) suppositories,
-Probanthine
Stool Softeners; Do not strain.
Bladder Spasms
Removed when urine clear to almost clear usually 24-48 hrs post op. Only with an order.
-May pass small clots and tissue debris for several days. -increase fluid intake to keep urine clear.
Incontinence an issue, due Kegels
Catheter Removal
Some urinary incontinence may occur. -Assure client this will probably disappear in time Discouragement occurs with incontinence -offer reassurance Dribbling can last up to a year kegel exercises will help 10-20 x/hr -try starting and stopping steam during voiding -urinate at first urge
Relieving Anxiety BPH
No valsava maneuvers, no rectal temps, or enemas for 1 week
-can cause hematuria and delay healing
Avoid sitting for long periods and strenuous exercise
-increases tendency to bleed
Drink plenty of fluids
-maintain hydration
-may avoid due to fear of incontinence or pain
Client teaching BPH
Healing requires from 4-8 weeks;
Avoid tubs while catheter in place.
Does not usually cause impotence.
-sexual intercourse may be resumed in 6 weeks.
Urine will be cloudy for several weeks
-Retrograde ejaculation. into the bladder come out cloudy
Client teaching BPH
Bleeding that persists after resting/lying down.
Clot formation; common after BM or increase activity (increase fluids and rest)
Heavy bleeding Call Dr.
Decrease in size of stream
Urinary retention
UTI symptoms or any s and s of infection
Avoid NSAIDs and ASA for 2 weeks.
Report to Physician BPH
normal process that occurs during cell cycles that help cells to specialize. Some of these alterations are helpful but in other cases the cells mutate and may become cancerous.
Differentiation
4 phases of cell growth and development.
Cell cycle
Process of making new cells that occurs in the somatic cells (tissues)
Mitosis
only occurs in the sex cells of the testes and ovaries.
Meiosis
Cell cycle is controlled by Cyclins which combine with and activate enzymes called cyclindependent kinases. Some cyclins stop the cycle from procedding and can result in the rapid proliferation of immature cells. In come cases these cells are considered cancerous.
Prostate Cancer
An increase in the number or density of normal cells. Under normal DNA control.
Hyperplasia
Cells differentiate into cell types not normally found at that location of the body. A protective reponse to adverse conditions often due to inflammation. Can be reversible when stressor goes away (Quit smoking)
Metaplasia
Occur in response to adverse conditions. Abnormal variant in size shape and appearance (Cervix-HPV virus)
Dysplasia
May occur in response to overwhelmingly destructive conditions inside the cell or surrounding tissue and is often associated with malignancies and used to grade the aggressiveness of the cancer cell. Not Reversable..
Anaplasia
Most common cancer in men.
-95% of prostate tumors are adenocarcinomas that grow on the outer portion of the gland
-Slow growing and spreads in a predictable pattern. (turtle in the box)
-Sites of metastasis; nodes, bones (sacrum, pelvis), lungs, liver.
Most common cause of pain is mets to the spin (usually thoracic)
Less incidence in Asian countries and Native Americans
Prostate Cancer
Age 1 in 8 over age 60
Diet high in animal fat (red meats) and Vitamin A.
Viruses
Vitamin E and D deficiencies
Genetic factors
-15% of men with prostate cancer have a 1st degree relative with it.
Race AA men have a higher incidence and at a younger age (60% increase than whites)
Having a vasectomy
Risk Factors of Prostate Cancer
Annual Digital Rectal Exam (DRE)
- Age 50; all men
- Age 45; AA men and any man with 1st degree relative with Prostate CA.
- Age 40-2 or more 1st degree relatives with Prostate CA.
American Cancer Society prostate Screening and Detection Guidelines
Often no symptoms if cancer is confined to the gland
-Symptoms of BPH and urinary tract obstruction
-Difficulty starting urination
With Mets to Bone-Lower back pain, hip pain or upper back pain
Pain during ejaculation
Malaise
Weight loss
Clinical Manifestations of Prostate Cancer
Screening is the most important due to ambiguous systems.
Hard, nodular areas felt on the prostate during digital rectal exam
Definite diagnosis is made only by prostate biopsy.
Dx of Prostate Cancer
Prostate Cancer confirmed Assess Mets' -Lymph node biopsy -CT Scan; Pelvis and Abdomen -MRI-para-aortic nodes and pelvic nodes -Bone Scan -Liver function studies
Additional Testing
Confined to Prostate. Non-palpable. Well differentiated
Stage 1 prostate cancer
Confined to prostate. Palpable. One or both lobes. Poorly differentiated.
Stage 2 prostate cancer
Extension of the tumor outside prostate capsule, possible seminal vesicle involvement.
Stage 3 prostate cancer
Extension of the tumor into surrounding tissues: lymph node involvement or distant metastasis.
Stage 4 prostate cancer
usually Rx when cancer is inoperable or signs of metastasis is evident.
-Lupron and Zoladex (inhibit the release of pituitary hormones that stimulate the production of testosterone)
-Flutamide (Eulexin) and bicalutamide (Casodex)
Antiandrogen inhibit production of testosterone.
Causes impotence, hot flashes, nausea, vomiting, chemical hepatitis and diarrhea.
Medication for Prostate Cancer
Hormonal Therapy
Can be used to treat localized tumors confined to the capsule.
-external beam to the prostate and surrounding lymph.
Brachytherapy (radioactive seed implantation) Iodine, gold, palladium or iridium
Treatment Prostate cancer
Radiation
Radical resection of the prostate
Surgery for Prostate Cancer
Open Radical prostatectomy Suprapubic prostatectomy Retropubic prostatectomy Perineal prostatectomy -does not perserve perineal nerves needed for erection. increases risk for incontinence
Prostatectomy
Robotic; Davinci Robot; laproscopic tools going inside a person.
Laporoscopic Radical Prostatectomy
Removal of both testicles
Done in conjunction with prostatectomy to cut off the testosterone supply to the prostate cancer
Orchiectomy
Laparoscopic surgery
-resume usual activites in one week.
Radical
-3 to 5 weeks of rest at home. Don’t lift anything heavier than 16 lbs.
Activity Post-op
Urinal Incontinence Nursing Care
- Kegel exercises can improve Stress incontinence
- Continence specialists
- Texas Catheter/leg bags
Nursing Care for Prostate Cancer Post op
Counseling for Erectile dysfunction.
Surgical treatments available.
Nursing Care for sexual dysfunction prostate cancer
pain; surgical and chronic with Mets
-radiation treatments home education.
-Sleep in a room alone for a week! Radiation can damage others. Avoid contact with pregnant women and children.
Use condom during sexual contact; ejaculate may be discolored.
Nursing Care for Prostate Cancer
when the stones form elsewhere in the urinary tract. ie. bladder
urolithiasis
Which statement by the patient, indicates proper learning has occured in regards to IVP precautions;
C. I need to tell the healthcare professionals of my shellfish allergy
Precautions prior to IVP.
intravenous pyelogram; with dye for kidney function
Priority nursing intervention for a patient with suspected water intoxication during a Turp procedure?
A. Tell the surgeon; bc procedure has to stop.
Post Turp complication: Water intoxication
With what symptom should the nurse notify the Dr. about with BPH?
A. no urine output last 12 hrs
B. Bladder scan for 650 ml
C. Post residual bladder scan of 350 ml
When to call the Dr. for BPH
Which of the following abnormally elevated labs, obtained prior to a percutaneous nephrostomy, should concern the nurse Most?
B. INR. risk for bleeding
precautions prior to percutaneous nephrostomy
