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NURS 620 Exam 3 > Exam 3 Renal Disorders > Flashcards

Exam 3 Renal Disorders Flashcards

1
Q

S/ SX of Dysuria

A
  • Subjective experience of pain or a burning sensation on urination
  • Frequency, urgency, hesitation
  • Can be secondary to several medical conditions or certain medications
  • Most commonly associated with lower urinary system infections
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2
Q

Dysuria: Differential Diagnosis

A
  • Most often associated with a bladder problem and rarely with renal disease
  • Inflammatory lesions of the prostate, bladder, and urethra
  • Other conditions associated with dysuria
    o Bladder tumors
    o Chronic renal failure
    o Nephrolithiasis
    o Disease of upper urinary system
  • Outside the renal system
    o STIs
    o Vaginitis and prostatitis
  • Women should be questioned about vaginal discharge or irritation
  • Symptoms may lead to other diagnoses
    o Urethral strictures
    o Prolapsed uterus
    o Pelvic peritonitis
    o Cancer of the cervix or prostate
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3
Q

Dysuria: Diagnostic Testing

A
  • Urinalysis is the easiest, most noninvasive, and most economical way to identify UTIs and other renal problems.
  • Once the associated condition is identified, appropriate treatment can begin.
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4
Q

Hematuria: Clinical presentation

A
  • Color of the urine
  • Concurrent symptoms?
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5
Q

Hematuria: History

A
  • Medications & dietary history
  • Menstrual history
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6
Q

Hematuria: Differential diagnosis

A
  • UTI / pyleo
  • Cancers
  • BPH
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7
Q

Hematuria: Physical exam

A
  • Abdominal exam – tenderness, masses, CVA tenderness, pelvic / prostate exam
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8
Q

Hematuria: Diagnostic tests

A
  • Urinalysis, C&S
  • ANA, CMP, CBC,
  • IVP, cystoscopy
  • Ultra sound
  • CT scan
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9
Q

Hematuria: Management and follow-up

A
  • Antibiotic therapy if bacterial infection found
  • Refer for further evaluation – urology or nephrology
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10
Q

Lower Urinary Tract Infection (UTI) differentiate between acute, chronic and complicated UTI

A
  • Acute infections
    Characterized by the onset of UTI in a previously symptom-free individual
  • Chronic infections
    Caused by obstructions, antibiotic-resistant bacteria, presence of multiple strains of bacteria
  • Complicated UTI
    Accompanied by factors that complicate the infection
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11
Q

Type of Lower Tract UTI

A

o Urethra: urethritis
o Bladder: cystitis
o Bladder wall: interstitial cystitis (IC)
o Prostate gland: prostatitis

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12
Q

Lower UTI: Clinical Presentation

A
  • Most frequently reported symptoms
    o Dysuria
    o Urinary frequency or urgency
    o Nocturia
    o Hematuria
    o Low back or suprapubic pain
    o Urinary incontinence
    o Cloudy, foul-smelling urine
    o Altered mental status in elderly
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13
Q

Lower UTI: Clinical Presentation UA

A

Urinalysis may exhibit
o Cloudy appearance
o Alkaline pH
o Hematuria
o Elevated levels of nitrites
o Leukocyte esterase
Urine sediments of
o RBCs, WBCs, mucus, and bacterial overgrowth

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14
Q

Lower UTI: Diagnostic Testing

A
  • Urinalysis
    o Clean-catch, midstream urine sample
    o Sample showing more than 100,000 organisms/mL is indicative of infection
    o PLUS presence of characteristic clinical symptoms
  • Urine culture is considered the gold standard for laboratory confirmation of UTI
  • Urinalysis with microscopy
  • Urine culture and sensitivity
  • IC: potassium sensitivity test (PST)
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15
Q

Lower UTI: Differential Diagnosis

A
  • Differential diagnosis
    o Tumors
    o Upper UTI
    o Vaginitis
    o STDs
  • Lower UTI does not exhibits signs of sepsis (fever, chills, WBC casts, CVAT)
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16
Q

Lower UTI: Management Uncomplicated

A
  • Pharmacological antimicrobial management is the mainstay of treatment
    o Nitrofurantoin (Macrobid) seems to be the most effective on gram-negative and gram-positive cocci;100 mg BID 7-day regimen 🡪 does not work in males!
    o Trimethoprim-sulfamethoxazole (Bactrim DS/Septra DS) is also effective; 1 DS x 3-day regimen for uncomplicated UTI
    o Amoxicillin; 500mg BID x 3 days
    o The fluoroquinolones have widespread efficacy
     BLACKLISTED for female patients, male patients be cautious…typically reserved for serious infections
  • Ampicillin and sulfonamides are becoming increasingly resistant
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17
Q

Lower UTI: Management Complicated UTI

A

o Ciprofloxacin 500mg po BID x 7-14 days
o Levaquin 250 mg po daily x 10 days or 750 mg daily x 5 days
* Do NOT use the same medication if one has been used in the last 3 months

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18
Q

Lower UTI: Management Pregnancy

A
  • During pregnancy
    o Especially important as an established link exists between premature delivery and UTI
    o Empirical therapy: amoxicillin 500mg po QID, nitrofurantoin 100 mg po BID x 7 days, or cephalexin (Keflex) 500 mg po QID x 7 days
    o Most treatment is 1 week
    o No Fluoroquinolones!!
    o No Bactim or Septra in the 1st or 3rd trimester of pregnancy!
    o History of UTI: postcoital prophylaxis
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19
Q

Lower UTI: Management
Fungal

A

fluconazole 200 mg qd 7–14 days

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20
Q

Lower UTI: Management
Chronic UTI

A

o Who should receive prophylaxis?
 2 or more symptomatic UTIs w/in 6 months
 3 or > within 12 months
* Prophylaxis should be initiated after previous UTI resolution is confirmed
* Daily dosing for 6 months
* Post-coital prophylaxis
* Self-medication (3-4 days of therapy when symptoms begin)

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21
Q

Lower UTI: Follow-up and Referral

A
  • Midstream, clean-catch urine sample for urinalysis
  • Indwelling catheters should be changed every 4–6 weeks
  • Maintain adequate hydration and monitor urine output
  • Obstructions must be identified and removed
  • Prescribe analgesics for patients to reduce pain associated with UTI
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22
Q

Lower UTI: Patient Education

A
  • Instruct patient to notify clinician if flank pain, hematuria, or lack of response to treatment occurs
  • Advise patient to
    o Complete full course of antibiotic therapy
    o Increase fluid intake to eight 8-ounce glasses of H2O
    o Take cranberry supplement and drink cranberry juice
    o Wear cotton underclothes
    o Avoid harsh soaps or feminine hygiene productsUse condoms
    o Use proper self-catheterization techniques
    o Empty bladder frequently, completely, and after sexual intercourse
    o Take showers instead of tub baths
    o Self-medicate as indicated
    o Keep a diary of urinary symptoms
    o Proper hygiene
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23
Q

UTI Males: Clinical presentation

A

-dysuria
-urgency/frequency
-cloud urine

24
Q

UTI Males: Treatment

A
  • Treat 10 to 14 days:
  • No macrolide
    o can still use Macrobid 100 mg po BID (as long as there is NO Prostatitis)
    o Bactrim DS 1 tab po BID
    o If associated with prostatitis
  • Ciprofloxacin 500 mg po BID or 1000 mg ER po daily
  • Levaquin 750 mg po Qday is only used for severe cases
25
Q

UTI Males: Differential Diagnosis

A
  • Prostititis
  • BPH
  • STI
26
Q

UTI Males: Diagnostic Testing

A

o UA/C+S
o Consider IVP or cystoscopy

27
Q

Interstitial Cystitis (IC): Clinical Presentation

A

Chronic inflammatory condition of the bladder clinically characterized by irritable voiding symptoms or urgency and frequency, in the absence of objective evidence of another disease

28
Q

Interstitial Cystitis (IC): Aggravating Factors

A

intercourse
perimenstrual status

29
Q

Interstitial Cystitis: Diagnostic Testing

A
  • Lab: diagnosis of exclusion
    GYN, U/S, IVP, Cystoscopy
  • PUF Symptom Scale (>5, IC likely)
    *Intravesical Potassium Sensitivity Test
30
Q

Interstitial Cystitis: Management

A
  • Oral Pentosan polysulfate sodium: 100mg TID or 200mg BID
  • Course duration: 2-4 months minimum
  • Intravesical DMSO bladder instillation
  • Bladder training (reduce eliminations)
  • Hydro-distension of the bladder
  • laser
  • low acid diet
  • NSAIDS, antidepressants, muscle relaxants
30
Q

Pyelonephritis: Clinical Presentation Acute vs Chronic

A

Acute
o May present with sudden onset of fever, shaking, chills, nausea, vomiting, unilateral or localized flank pain, fatigue, diarrhea
o Otherwise may be largely asymptomatic
o Elderly patients may present with altered mentation
Chronic
o fatigue, nausea, decreased appetite with weight loss, nocturia and/or polyuria, symptoms of renal failure
o Usually first diagnosed when patient presents with impaired renal function caused by damage to the kidneys

31
Q

Pyelonephritis: Clinical Presentation- Physical exam

A

o Marked tenderness on deep abdominal palpation
o May be hypertensive

32
Q

Pyelonephritis: Diagnostic Testing

A
  • Diagnosis confirmed through urinalysis & CNS, which is positive for bacteria, proteinuria, leukocyte esterase, urinary nitrites, hematuria, pyuria, and WBC casts
  • Urine culture, which typically demonstrates greater than 100,000 cfu/mL
  • Blood cultures
  • Cystoscopy with ureteral catheterization
  • Renal ultrasound or IVP
33
Q

Pyelonephritis: Differential Diagnosis

A
  • Difficult to differentiate from cystitis; however, presence of WBC casts is diagnostic for pyelonephritis
  • Definitive diagnosis for chronic disease is made by identifying persistent pyuria and by positive urine cultures
  • Kidney biopsy is sometimes appropriate for diagnosis
33
Q

Pyelonephritis: Differential Diagnosis

A
  • Difficult to differentiate from cystitis; however, presence of WBC casts is diagnostic for pyelonephritis
  • Definitive diagnosis for chronic disease is made by identifying persistent pyuria and by positive urine cultures
  • Kidney biopsy is sometimes appropriate for diagnosis
34
Q

Pyelonephritis: Management

A
  • Aggressive therapy is necessary to prevent permanent damage
  • Oral antibiotics for mild cases
    o Septra DS or Cipro (cautiously!)
  • Hospitalization of patients who are pregnant, vomiting, or dehydrated should be considered
  • Treatment courses should typically last 7–10 days for mild to moderate, 14 days for severe, and 21 days for particularly slow responders
  • If patient does not respond within 48 hours
    o Reevaluate patient and cultures
    o Consider hospitalization
    o Ultrasound, IVP, or dimercaptosuccinic acid (DMSA) renal scan
    o IV antibiotics
    o Increase fluid intake and maintain an accurate intake and output record
    o Surgery may be indicated
    o Diagnostic studies requiring insertion of instruments should be delayed
35
Q

Pyelonephritis: Follow-up and Referral

A
  • Patient should be assessed 48 hours later to assess responsiveness to therapy and consideration for discharge
  • Recurrent pyelonephritis
    o Reculture at 2, 6, and 12 weeks after antibiotic therapy is initiated
  • Chronic pyelonephritis: refer to nephrologist
36
Q

Pyelonephritis: Patient Education

A
  • Focus is on preventing recurrence
    o Complete antibiotic therapy
    o Prevent lower UTIs
  • Increase fluid intake
  • Report recurrence of any symptoms immediately
  • Take cranberry supplements and drink cranberry juice
  • Control hypertension with medications
37
Q

Kidney Stones: Different Kinds

A

Stones form from
o Calcium *
o Struvite
o Uric acid
o Cystine

38
Q

Kidney Stones: Clinical Presentation

A
  • Sudden flank pain
  • Can radiate to abdomen, groin, perineal, and inner thigh
  • Nausea/vomiting
  • Urinary frequency
  • Diaphoresis
  • Dysuria
  • Hematuria
  • Weakness
39
Q

Kidney Stones: Physical Exam

A

Vital signs
* Elevated BP, tachycardia, tachypnea
Systemic
* fever
Abdomen
* Distended
* Guarding
* Decreased/absent bowel sounds
* CVA tenderness

40
Q

Kidney Stones: Diagnostics

A

UA
o Normal to hematuria and leukocytes
o Crystals and cast
o Pus
o Alkaline or acidic pH
CBC-infection?
CMP
Renal/bladder ultrasound
Bladder x-ray
Noncontrast CT

41
Q

Kidney Stones: Differential Diagnosis

A

Appendicitis
UTI
Pyelonephritis
PUD
Ovarian cyst
Tubal pregnancy
Renal/bladder cancer

42
Q

Kidney Stones: Treatment

A

 Pain relief
* Oral NSAIDs
* Oral Opiates
* Antispasmodics
* Warm compresses
* Focused breathing/diversional therapy
Thiazide diuretics-calcium
Allopurinol-uric acid
D-penicillamine-cystine
Increase water intake
Noninvasive and invasive surgical interventions
May need hospitalization for severe symptoms/referral
Avoid medications that can cause stone formation
* TUMs
* Loop diuretics
* Vitamin supplements

43
Q

Chronic Kidney Disease: Clinical Presentation

A

Usually asymptomatic until GFR declines 10-15% from normal
 Anorexia
 Lassitude
 Fatigability
 Weakness
 Pruritus and dry skin
 N/V
 Hiccups
 Emotional lability
 Depression
 Insomnia
 Confusion
 Bruising
 Peripheral Neuropathy
 Edema
 Headaches
 Urine odor to breath
 Metallic taste
 Impotence
 Nocturia
 Muscle cramps
 Gout
 Pale
 Frost appearance to urine
 Ascites
 Proteinuria
 Crackles in lungs
 Pericardial rub
 Elevated BP

44
Q

CKD: Diagnostics

A

 BMP
 BUN, creatinine, and creatinine clearance
 GFR
Staging:
 Stage 1
* Persistent Albuminuria, normal GFR
 Stage 2
* Persistent Albuminuria, GFR between 60 and 89
 Stage 3
* GFR between 30 and 59
 Stage 4
* GFR between 15 and 29
 Stage 5
* ESRD, GFR less than 15
 CBC
o Anemia
 UA
o Proteinuria
 24-hour urine studies
 Renal ultrasound
 Renal CT, CT angiography
 MRI/MRA
 Duplex Doppler ultrasonography

45
Q

CKD: Management

A

 Control any underlying comorbidities
* HTN
– Target BP 125/75 (JNC 8 says <140/90?)
 DM
 Anemia
 Fluid restriction
 Sodium restriction
 Protein restriction (0.58g/kg daily)
 Adequate caloric daily intake (40-50cal/kg daily)
 Referrals
 Nephrology
 Nutritionist

46
Q

Urinary Incontinence:
Stress Clinical Presentation

A

 Increase in abdominal pressure results in loss of urine
 Urethral sphincter muscle is weak
 Weakness in pelvic floor muscles (preg, menopuas)
 Brought on by coughing, sneezing, straining
 Small Leakage

47
Q

Urinary Incontinence:
Stress Incontinence Management

A
  • Kegels: 40 to 60 contractions daily
    o Slow tighten for 10 seconds, hold for 10 seconds, release over 10 seconds
     Pelvic floor muscle training (PFMT)
     Vaginal cones or pessaries
    o Must be measured, have to be resized after baby or weight changes
     Lose weight
     Limit fluids and diuretics in evening
     Dietary changes and quit smoking
     Meds: vaginal estrogen
     Surgical intervention
48
Q

Urge Incontinence:
Urge Incontinence

A

 Detrusor instability
 Involuntary leakage of urine resulting from inability to delay voiding
 Patient has sensation of a full bladder, but cannot store urine long enough to reach the bathroom

49
Q

Urge Incontinence:
Urge Incontinence Management

A

Anticholinergic medications Tricyclic antidepressants

50
Q

Urge Incontinence:
Overflow Incontinence

A

 Involuntary leakage of small amounts of urine
 Caused by over-distended bladder in an individual who does not feel sensation to void
 Caused by outlet obstruction, BPH, medications

51
Q

Urge Incontinence:
Overflow Incontinence Management

A

Treatment of underlying cause Indwelling catheterization

52
Q

Overactive Bladder (OAB): Clinical Presentation

A

 Unable to postpone–urgency

53
Q

Overactive Bladder (OAB) Management Non-Medication

A

 Behavioral therapy techniques: bladder training, urgency control strategies
 Avoid bladder irritants
o Common bladder irritants: cold remedies (Sudafed), chocolate, carbonation, colas, citrus, cranberry juice or pills, vitamin C, certain wines and beers, Crystal Light, candy and high sugar foods, smoking

54
Q

Overactive Bladder (OAB) Management Medication

A

 Anticholinergic /Antimuscarinic Medications
o Oxybutynin – Ditropan and Ditropan XL po and patch
o Trospium Chloride – Sanctura
o Tolterodine - Detrol and Detrol LA
o Solifenacin – Vesicare
o Fesoterodine - Toviaz
 Major side effects: dry mouth, urinary retention, constipation, blurred vision (caution in elderly and in glaucoma)

NURS 620 Exam 3 (2 decks)

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