exam 3 Flashcards
oliguria
decreased urine output, less than 400 mL / 24 hours
anuria
urine output of less than 100 ml in 24 hours
Normal urinary output for adult: 30 ml / hour
azotemia
syndrome that results from increased BUN & creatinine together
polyuria
increased urine output, more than 2000 mL in 24 hours
uremia
a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys
Manifestation of renal failure
normal specific gravity
1.000 - 1.030
range of urine ph
4-8
serum creatinine normal level
0.2-1.0 mg/dl
normal BUN
8 - 20 mg/dl
is 50% of your kidney function is compromised, what will be elevated?
creatinine
urethral stricture
Narrowing of urethra
Causes obstruction of outflow of urine → can lead to urine stasis and UTI
Can develop overflow incontinence
how to tx urethral stricture (surgery)
urethroplasty - repair urethra
which is worse, AR or AD PKD
AR - 100% of nephrons are involved
4 common side effects of UTIs
Dysuria = painful when voiding
Frequency - peeing continuously
Urgency - have to go right now
Nocturia - have to go in the middle of the night
if BUN is rising more than creatinine…
may not be a renal issue
KUB films
kidney, ureter, and bladder x-rays
Aka flat plate of the abdomen
A to P view of what’s going on in abdomen
when would you use cystoscopy/cystography/VCUG (4)
Done to diagnose bladder or urethral trauma
Done to see why frequent UTIs
Remove tumor in urinary tract
Examine enlarged prostate
process for cystoscopy/cystography
Ask patient to void
Catheter
Sterile saline → fill bladder
Get pictures
Voiding cystourethrography (VCUG) process
have person stand, remove saline, and watch how bladder contracts to empty
Shows if there are problems with motion of bladder wall
do cystoscopy/cystography/VCUG require consent
yes
when you remove a foley, is it normal for first void to sting
yes
if it stings after that, need to call provider
causes of cystitis
Usually d/t infection but not always
Usually e.coli ascending urethra into bladder → infection
Can also be virus, fungus or parasites
Catheter related infections are common
what is the most common cause of sepsis
cystitis
what can cause non infectious cystitis
can be d/t chemo or chemical irritation
what is interstitial cystitis
unknown cause, not infectious
could be an allergic response
how to dx cystitis
Urinalysis with culture and sensitivity
for chronic, recurring infections of cystitis, how do you tx
long term antibiotics
what is urethritis
inflammation of urethra that causes s/s of UTIs
in what population is urethritis common in and how do you treat them
post menopausal women, especially if sexually active
tx with estrogen cream
what is urethral stricture and what type of incontinence can it lead to?
Narrowing of urethra
Causes obstruction of outflow of urine → can lead to urine stasis and UTI and overflow incontinence
stress incontinence cause
Due to weakening of the bladder neck, often associated with childbirth
stress incontinence s/s
Incontinence when sneezing, coughing, laughing, exercising
Small amounts leaked
stress incontinence tx
Pelvic floor exercises = Kegels
Spacing fluid during the day
Incontinence diary
Topical estrogen therapy for postmenopausal therapy
Reconstructive surgery for uterus or bladder prolapse
Implanted sacral nerve stimulator - reminder to kegel
Tens units
urge incontinence definition and cause
- Loss of urine r/t strong need/desire to urinate and inability to suppress signal for same = overactive bladder
- May be secondary to Parkinsons, MS, stroke
interventions for urge incontinence
Behavioral interventions
Diet therapy - stay away from caffeine, alcohol, stimulants
Drugs - anticholinergics for smooth muscle relaxation, antihistamines, etc.
Bladder training
Pelvic floor exercise
Interval training
Space fluid intake, and limit fluid after dinner
what causes overflow incontinence
Detrusor muscles fail to contract so bladder over extends –> Constant dribbling of urine to avoid bladder rupture = underactive bladder
Can be associated with meds
Diabetes, spinal cord injuries, MS, BPH, uterine prolapse
overflow incontinence interventions
Intermittent catheterization (maybe for spinal injury)
Surgery if outflow is obstructed (like BPH)
Meds - depends on cause
BPH - flomax
functional incontinence cause
Caused by factors other than urinary tract issues like
Loss of cognitive function
See this in Alzhemiers and other dementias but never assume dementia is the reason (could be BPH)
functional incontinence interventions
Treat any reversible causes first Skin protection Urine containment Caregiver would need the urinary training - i.e. walk patient to bathroom, etc. Condom caths at night, Diapers for women Intermittent catheterization
mixed incontinence
We don’t always figure out the reason for incontinence
Features of more than 1 type of incontinence
what is urolithiasis
Presence of calculi (stones) in urinary tract
Majority of stones are made of calcium but not all (some can be bacterial)
can stones damage the lining of the urinary tract
yes
risks d/t urolithiasis
Retention from retained urine
Hydronephrosis - stone in kidney
Can be seen in ureter
what can contribute to urolithiasis
Metabolic defects Immobilization Urinary retention Loop diuretics Antacids, steroid therapy, fiofelan
is a high calcium diet associated with urolithiasis
no - high calcium diet should not promote stone formation
s/s of urolithiasis
Sudden onset of extreme pain Hematuria Oliguria Ureteral spasm N/V secondary to pain Pallor and diaphoresis Potential for shock d/t nearby SNS nerves Potential for hydroureter &/or hydronephrosis = obstructive stone
does a stone that isn’t moving cause pain
no
what labs/tests do you do for urolithiasis
Lab assessment - chemistries, hematology, UA
Elevated WBC - infectious process
KUB x ray can see stones
CT scan w/o contrast
how do you treat urolithiasis pain
Opiates, injectable NSAIDs (toradol), antispasmodics
Complementary and alternative therapies
Heat → dilation
walking helps pass the stone
Shock wave lithotripsy (SWL) w/ stents
What type of sedation, how is it done, etc.
fluoroscopic procedure Under moderate sedation IV Cardiac monitoring Aim a shock wave at location of the stone and blast it with sound/shock wave so they can pass it
what are 2 other surgical ways to treat urolithiasis
Retrograde ureteroscopy
Open surgical procedure (if the above and the shock waves don’t work)
pt teaching post surgery for urolithiasis (3)
Strain urine
stay hydrated
antibiotics
which PKD is more common: AR or AD and when does it manifest
AD, manifests later in life
how many nephrons are involved in AR PKD
100% of nephrons are involved from time they are born
Children usually die early in childhood
how does PKD impact the kidneys
Fluid filled cysts in nephrons → prone to rupture → pressure in kidney area
Pressure within kidney causes nephrons to become not functional
Grossly enlarged kidneys - look like grape clusters
Cysts damage glomerulus and tubules
where else can you get cysts from PKD (3)
Berry aneurysms
Liver cysts
Cardiac vasculature cysts
PKD pain: acute
when cysts rupture, sharp pain over flank, pain is worse
PKD pain: chronic
all the time because of cysts, pressure, discomfort
s/s of PKD
Distended abdomen - enlarged kidneys press on bowel
constipation
Hematuria/cloudy urine
Kidney stones are common
Nocturia & proteinuria
HTN b/c of renal ischemia → can lead to aneurysms
Edema b/c of high sodium levels (d/t renal ischemia)
N/V, anorexia
pruritis
what is an early sign of PKD
nocturia
how do you treat PKD
- treat chronic and acute pain - can needle aspirate through the back to the cyst
- antibiotics for infection
- stool softener
- BP medications
- diet therapy - increase fiber and decrease Na+
are ASA or NSAIDs encouraged for PKD
no
self teaching for PKD (3)
Take temp if feel ill
See MD for unremitting headache or visual changes (could be cyst elsewhere)
Call MD for foul smelling urine = sign of infection
what can Hydronephrosis, hydorturerer and urethral stricture result in
overflow obstruction
causes of Hydronephrosis, hydroureter and urethral stricture
Tumors Stones Trauma to renal system Congenital defects Scar tissue Radiation therapy for urological cancers
how to dx Hydronephrosis, hydorturerer and urethral stricture
CT or US
interventions for Hydronephrosis, hydroureter and urethral stricture
Catheterization as needed
Double voiding
Monitor bladder distension - gentle palpation
Bladder scan
nephrostomy tube
If huge stone is obstructing - undergo fluoroscopy and drain ureter through the patients back→ reroute urine to decrease pressure
*do not have patient lie on their back
what to be mindful of before nephrostomy tube placement
NPO before
Clotting studies or correct if not normal before procedure
Pain control before procedure
how long is bloody urine expected for after nephrostomy tube placement
24 hours
if there is recurrence of pain after nephrostomy tube, what might that mean
tube could have been displaced
Check urine output and report to provider
acute pyelonephritis: cause
Bacterial infection of the kidney
Can be primary of urinary tract Or can be obstruction
Usually a bladder infection that has ascended!
s/s of acute pyelo
Fever, chills, tachycardia and tachypnea Flank or back pain Abdominal discomfort Significant N/V May not be able to take PO antibiotics May have urgency, frequency, nocturia General malaise or fatigue dehydration
chronic pyelo: 4 causes
numerous episodes of acute pyelo in the past
Stones
Neurogenic impairment of voiding
Kinked ureter
s/s of chronic pyelo
HTN!
Very dilute urine/nocturia - can’t concentrate
hyponatremia, hyperkalemia, acidosis
tx for chronic pyelo
Urinary diversion surgery
Unkink ureter via surgery
Antibiotic but might be long term
what is the leading cause of ESRD
diabetic nephropathy
what is the 1st manifestation of diabetic nephropathy
albuminuria
how do you prevent diabetic nephropathy
Manage glucose levels!
Check eyes yearly! Retinal changes parallel renal changes
how to tx diabetic nephropathy
Avoid nephrotoxic agents
Avoid dehydration
Might need to reassess insulin requirements because failing kidneys can lead to hypoglycemia
BPH population
Men, age 50, decrease in male hormones, Increase in DHT
physiologic manifestations of BPH
Detrusor muscle hypertrophies - can’t contract effectively
Prostate swells and puts outflow obstruction on urinary tract
what can BPH lead to
Leads to UTI d/t retained urine Acute or chronic urinary retention Kidney stones, bladder stones Hydroureter or hydronephrosis Urinary overflow incontinence → dribbling Can go into renal failure
plus lower urinary tract symptoms (hesitancy, difficulty maintaining stream, decreased force of stream, dribbling, hematuria, nocturia, etc.)
what is severe BPH
Higher levels of protein made by androgen related gene
bladder damage and more renal involvement
is there a link b/w BPH and ED
Coexist together in people with BPH
tx for BPH
Lifestyle: more frequent intercourse
meds:
- 5 alpha reductase inhibitors (procar)
-alpha antagonists (flomax) (don’t take w/ viagra!)
others: saw palmetto, botox, viagra (in testing)
PSA level less than 4 is..
normal
PSA greater than 10
associated w/ prostate cancer
should labs be drawn before or after digital exam
Labs need to be drawn and sent off before digital exam
If not before, you can have falsely elevated PSA
general characteristics of surgery for BPH
All can be done outpatient
Local anesthesia
No foley, few complications
Removes excess prostate tissue
what is thermotherapy and what is it used for
BPH
destroy tissue and stents are placed to keep prostate patent
ex: tuna, tunt, and Ilc
when would you use more traditional therapies for BPH
Used when other complicating issues are involved
Acute urinary retention, hematuria, chronic UTIs, high urinary residuals, hydroureter, hydronephrosis
Transurethral resection of the prostate = TURP
Excess prostate issue is removed via endoscope under epidural or spinal anesthesia
Stricture, might need repeat surgeries
No surgical incision line
Long term sexual function should not be affected
adverse effect of the TURP
Can have retrograde ejaculation for some time → into bladder
2 other surgeries for BPH w/ other factors
TUIP - transurethral incision of prostate
Open prostatectomy. -Entire prostate is removed under general
after BPH surgery, how long do you have CBI for
24 hours
characteristics of foley for post BPH surgery
3 way catheter w/ 30-45 ml balloon (Normal foley = 10ml balloon) Tape to leg Run irrigant (NS) into bladder
how often should you look at urine outputs post BPH surgery while foley is in
hourly
need to get out what you’ve put in plus a little more!
what is the most common cancer in men
prostate cancern, slow growing, predicatble
when do you screen for prostate cancer
over 50, annually
risk factors for prostate cancer
Diet high in animal fats
Age
Vietnam vets d/t agent orange
what is EPCA-2
early prostate cancer antigen
New serum marker just for prostate cancer
prostate cancer surgery: types and indication
Can be indicated if cancer is resistance to radiation
MIS - usually minimally invasive
Open radical surgery
Laparoscopic radical prostatectomy (LRP)
what are complications post radical prostatectomy
Usually sterile after
Urinary incontinence - might be permanent
Impotence (ED) - lasts 3-18 months
what are non surgical options for prostate cancer
Radiation seed implants
External radiation
hormonal therapies - androgen deprivation
chemotherapy
cryotherapy —> can lead to ED and incontinence
what are precautions for radiation seed implants
Anyone under 3 should not be in lap
Less than 5 mins per day per child
what are s/s of androgen deprivation therapy
LH releasing hormone agonists to release more testosterone
s/s: onset of ED, hot flashes, gynecomastia
what is a fistula and where is it located
Attaching artery to vein
forearm, upper arm or thigh
what to know about a AV fistula, graft or shunt
No BP readings in the affected extremity
No venipuncture
Palpate for thrills; auscultate for bruits
Assess distal pulses - want to ensure good blood flow
Encourage routine ROM of extremity
Check for bleeding at the site
Assess for manifestations of infection
Teach patient how to guard their graft/shunt
for patients w/ renal failure, how do you manage excess fluid volume
Daily weights!
Fluid restrictions
Assess for overload/crackles and JVD
what are dietary considerations for renal failure patients
Protein - restrict as renal failure worsens
Fluid (urine output + 500 ml/day usually for all input)
K+
Na+ - limit b/c of thirst and HTN
Phosphorus - limit
Water content of foods
does hemodialysis or peritoneal dialysis have more dietary restrictions
hemodialysis
what are neuro changes in the elderly
Intellect does not decline with age
Perceived changes are related to drug interactions, less sleep
Response time - can take longer for older adults to learn or process something new
what causes memory changes in the elderly
Decreased number of neurons
Brain size atrophies
Recent memory is less clear than distal memories
sensory changes in the elderly (3)
Touch sensation is diminished with age
Hearing is less acute
Pupils are smaller in general - need more light to see
motor changes in the elderly (4)
Movement is slower
Balance changes
Coordination changes
Postural changes
before doing a neuro check on a patient, what must you know
their baseline
what could cause acute changes in mental status
infectious process elsewhere in the body
what is the first sign CNS function has declined
changing LOC
stuporous characteristics
can be roused with vigorous painful stimuli
comatose
cannot increase LOC no matter what
PERRLA
Equal, round, reactive to light and accommodate
what can alter the shape/appearance of pupils
Surgeries Eye meds Cataracts Dry eye syndrome Traumatic injury
what is a late sign of neuro deterioration
can have dilated pupil or non reactive pupils
lowest score of glasgow coma
3
highest score of glasgow coma
15 = higher functioning
when do you test response to painful stimuli
GSC score of less than 6
1st way to get test response to painful stimuli
use normal voice, then go to loud voice then give gentle tap or shake (not for trauma pt)
Supraorbital pressure: Feel ridge of eye socket - gentle pressure
Trapezius squeeze - thumb in juncture of neck and chest and squeeze
Sternal rub w/ knuckles - should be last
2nd way to test pain response
peripheral pain assessment
Test all extremities for responsiveness
Press pencil on cuticle
how to assess motor function
MAE - moving all extremities
Assessment of strength in each extremity
Grasps
Push on the gas, pull your toes up to toward your head
how to test sensory function
Sharp vs dull
2 point discrimination - close their eyes and ask them to tell you which toe you’re touching
what does a CT look at
w/ or w/o contrast
Contrast is iodinated
Looks at structural changes
what is a magnetic resonance spectroscopy used for
alzheimers
strokes
what is an MRI used for
Looks at soft tissues
Also MRA/MRV
Uses gadolinium (not iodine)
what is a PET scan used for and how do you prep a patient for it
Malignancies
Cerebral blood flow
Prep:
- NPO 6 hours before
- Should not get insulin 6 hours before and no metformin to avoid lactic acidosis
what does an EEG do (6)
Evaluate brain activity Determine site of seizure origin Diagnose sleep disorders Monitor activity during anesthesia Determine brain death Degenerative brain disease
how to stimulate brain for EEG
Photo stimulation
Auditory stimulation evoked potential to assess hearing loss or auditory nerve damage
Somatosensory evoked potential - delivery tiny shocks to check for nerve degenerative disease/disorders
what are migraines
Associated w/ spasm of cerebral arteries
Chronic, episodic disorder, usually 4-72 hours
Pain usually worse behind one eye or ear
if someone has a migraine new onset after 50
have neuro imaging done
s/s of migraine
Unilateral, fronto temporal throbbing pain, with phonophobia, photophobia, N/V, sensitive scalp
what are triggers for migraines
Dietary - cheese, chocolate, nuts, caffeine, yeasts, smoked foods, artificial sweeteners, red wine
Physiologic changes: sudden drops in blood glucose, skipping meals, anger, mood changes, fatigue
Meds: missed medications, nifedipine, nitroglycerin, estrogens
Big changes in barometric pressure and weather
