Renal/Urinary

Question 1

Is urinary incontinence a normal part of aging?

Answer 1

• Incontinence isn’t a “normal part of aging” but is more prevalent in the older adult
• Some changes in the urinary tract as we age can contribute: (1) bladder capacity, (2) contractility and (3) ability to postpone voiding can decline as wel age
• Some things may enlarge (such as prostate)

Question 2

What questions do you ask to determine the patient is incontinent?

Answer 2

1. Ask about the onset of incontinence and for a description of the incontinence pattern.
2. Obtain a description of normal urinary pattern and fluid intake. Inquire about other urinary problems, such as hesitancy, frequency, urgency, nocturia, dysuria, and decreased force or interruption of the urine stream.
3. Ask about a history of urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, COPD, chronic cough, diabetes, obesity, or surgery involving the bladder, prostate, or pelvic floor.
4. Ask a female patient about the number of pregnancies and childbirths.
5. Ask about smoking, alcohol, and caffeine use.
6. Obtain a complete drug history.

Question 3

What is incontinence?

Answer 3

Uncontrollable passage of urine
Can be transient or permanent
Possibly involving large volumes of urine or scant dribbling
Classified as stress, overflow, urge, or functional

Question 4

Normal bladder capacity

Answer 4

Normal functional bladder capacity in adults ranges from approximately 300 to 400 ml

Question 5

What is anuria?

Answer 5

Lack of urine production

Question 6

What is dyuria?

Answer 6

Painful or difficult urination

Question 7

What is urinary frequency?

Answer 7

Urinary frequency is the need to urinate many times during the day, at night (nocturia), or both but in normal or less-than-normal volumes.

Question 8

What is hematuria?

Answer 8

Presence of blood in the urine

Question 9

What is nocturia?

Answer 9

Nocturia is a condition that causes you to wake up during the night to urinate. This can be thought of as nocturnal urinary frequency.

Question 10

What is oliguria?

Answer 10

Oliguria is a medical term for low urine output (how much you pee). In the case of an adult, this means less than 400 milliliters (mL) to 500 mL (around two cups) of urine per 24 hours. The numbers depend on weight in terms of children and infants.

Question 11

What is proteinuria?

Answer 11

Elevated levels of protein in the urine

Question 12

What is microalbumin?

Answer 12

Less than 30 mg is normal. From 30-300 mg indicates microalbuminaria.

Question 13

What is pyuria?

Answer 13

Pyuria is a condition defined by the increased presence of white blood cells in urine. Although a urinary tract infection is the most common cause of sterile pyuria, other conditions may be involved. the presence of 10 white blood cells in each millimeter cube of the urine. Sterile pyuria, in contrast, is a type of pyuria in which no bacteria are present in the urine. This could be due to a medical condition, non-detected bacteria, or another germ, such as a virus.

Question 14

What is enuresis?

Answer 14

Involuntary urination at night

Question 15

What medications help with urinary/renal disorders?

Answer 15

Estrogen •Oxybutynin •Dicyclomine •Tolterodine

Question 16

What are some causes of UTI?

Answer 16

Community vs CAUTI (catheter associated) •Urinary stasis •More common in woman •Lower UTI ◦Urethritis ◦Cystitis ◦Prostatitis •Pyelonephritis

Question 17

What are the symptoms of a UTI?

Answer 17

• Dysuria •Polyuria •Coudy urine •Urgency and frequency •LOC changes

Question 18

How do you test for UTI?

Answer 18

• U&A C&S - CBC

Question 19

How are UTIs treated?

Answer 19

• ABX - push fluids - cranberry juice - education

Question 20

What is pyelonephritis?

Answer 20

Upper UTI involving the kidneys - symptoms incl lower back pain and fever - Can be acute or chronic

Question 21

Describe the differences between acute and chronic pyelonephritis?

Answer 21

Acute:

• bacterial in origin
• will improve with antibiotics, fluids
• symptoms usually moderate-severe
• chronic diseases like diabetes

Chronic:

• Nonbacterial in origin
• Caused by unresolved UTI, long-term HTN, vesicoureteral reflux, urinary obstruction
• may progress into renal failure
• symptoms usually manifest mildly
• chronic diseases like diabetes

Question 22

What tests are available for pyelonephritis?

Answer 22

◦UA C&S ◦Specific gravity ◦GFR ◦Creatinine

Question 23

What is the treatment for pyelonephritis?

Answer 23

◦Same as UTI but likely need IV and/or longer therapy ◦Educate

Question 24

Urolithiasis/ Nephrolithiasis/Ureterolithiasis

Answer 24

•Obstruction •Calculi (stones) ◦Calcium ◦Uric acid and cystine ◦Bacteria •Dehydration

Question 25

What are some potential sites of urinary calculi?

Answer 25

-Right & Left kidney - renal stones - ureters -bladder

Question 26

What are the S/S of urinary calculi?

Answer 26

* Pain * Frequency/dyuria/anuria * hydronephrosis * hydroureter

Question 27

How is urinary calculi diagnosed?

Answer 27

◦UA ◦WBC, Ca, Phos, uric acid, BUN, Creatine ◦CT scan

Question 28

What methods of treatment are available for kidney stones?

Answer 28

Extracorporal shock wave lithotripsy Scope (uteroscope)

Question 29

Why would a urinary diversion be used?

Answer 29

* bladder cancer or other pelvic malignancies * birth defects * Trauma strictures * neurogenic bladder * chronic infection or intractable cystitis * used as a last resort for incontinence

Question 30

What are the types of urinary diversions?

Answer 30

* Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy * Continent urinary diversion: Indiana pouch, Kock pouch, uretherosigmoidostomy

Question 31

What is chronic kidney disease?

Answer 31

* Worsening kidney function over time * Hypertension * Diabetes * Loss of ability to produce diluted urine * Nephrosclerosis * AKA Hypertensive nephropathy * Diabetic Nephropathy

Question 32

What are the manifestations of CKD?

Answer 32

—Decreased GFR —Oliguria or anuria —Uremic frost —Anemia —FVO —Electrolyte imbalances ◦See lab values on page 1379 —Effects on every body systems ◦See chart KEY FEATURES pg 1388

Question 33

What are the stages of CKD?

Answer 33

* Stage 1 with normal or high GFR (GFR \> 90 mL/min) * Stage 2 Mild CKD (GFR = 60-89 mL/min) * Stage 3 Moderate CKD (GFR = 30-59 mL/min) * Stage 4 Severe CKD (GFR = 15-29 mL/min) * Stage 5 End Stage CKD (GFR \<15 mL/min)

Question 34

What is the tx of CKD?

Answer 34

—Medication management chart page 1391 —Frequent labs —Diet ◦Watch fluid, K, NA, Phosphorus, and protein ◦see table 63.8 page 1392 —F/E balance —Manage comorbidities —Peritoneal dialysis ◦At home ◦May cause peritonitis with pink or bloody discharge ◦Clear Dialysate —Hemodialysis ◦Settings and anticoagulation —Transplant

Question 35

What are considerations for hemodialysis?

Answer 35

—Fistula ◦No bp cuff ◦Palpate and auscultate ◦Takes months to heal from placement —Common care considerations ◦F/E ◦Meds to hold —Post dialysis assessment —Disequilibrium

Question 36

What is a renal cell carcinoma?

Answer 36

Renal cell carcinoma is a malignant neoplasm of the kidney; it comprises several distinct morphologic types, some of which are familial Patients may be symptomatic (eg, hematuria, flank pain), but very often the lesion is found incidentally on imaging for unrelated reasons Treatment of localized disease is primarily surgical. Nephron-sparing treatment (partial nephrectomy) is favored for stage I and, when feasible, for stages II and III; radical nephrectomy is recommended for surgical candidates with large or complex tumors Thermal ablation is an option for smaller lesions in patients who cannot undergo surgery; active surveillance without immediate intervention is also an option for selected patients with small lesions (stage I, less than 2 cm 1)

Question 37

What is BPH?

Answer 37

—Enlargement of the prostate —Effects half of men over age 50 and 80% of men over age 80

Question 38

What are the s/s of BPH?

Answer 38

—s/s- looks like urinary obstruction, retention, and UTI ◦Hyrdroureters and hydronephrosis —May experience overflow incontinence

Question 39

What is prostatitis and how is it treated?

Answer 39

◦Inflammation caused by an infectious agent ◦Treatment –Antibiotics –Pain management –Spasm control

Question 40

What labs and tests are ordered for BPH?

Answer 40

—Labs- ua, cbc, psa, bun/creat, prostatic fluid —Diagnostics- DRE and Transabdominal or transrectal ultrasound, cytoscopy

Question 41

How is BPH treated?

Answer 41

—Treatment ◦Meds chart page 1474 –Finasteride –Tasulosin –Tadalafil - doxazosin ◦Catheter ◦Prostate surgery-TURP

Question 42

What is Transurethral resection of the prostate (TURP)

Answer 42

Transurethral resection of the prostate (TURP) is a surgery used to treat urinary problems that are caused by an enlarged prostate. An instrument called a resectoscope is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The resectoscope helps your doctor see and trim away excess prostate tissue that's blocking urine flow. TURP is generally considered an option for men who have moderate to severe urinary problems that haven't responded to medication. While TURP has been considered the most effective treatment for an enlarged prostate, a number of other, minimally invasive procedures are becoming more effective. These procedures generally cause fewer complications and have a quicker recovery period than TURP.

Question 43

What does management look like after TURP?

Answer 43

* Monitor urinary drainage and keep catheter patent * Assessment of pain * Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter. * Medication and warm compresses or sitz baths to relieve spasms * Administer analgesics and antispasmodics as needed * Encourage patient to walk, but to avoid sitting for prolonged periods. * Prevent constipation * Irrigate catheter as prescribed

Question 44

What is CBI?

Answer 44

often done after TURP Continuous bladder irrigation (CBI) is a medical procedure that flushes your bladder with a sterile liquid. It also removes urine (pee) from your body at the same time. Healthcare providers often use it to prevent or remove blood clots after surgery on the urinary system. The procedure takes place in a hospital over several days.

Question 45

What is pt teaching about BPH and after TURP?

Answer 45

—Diet low in fat and red meat, high in protein and vegetables —Adequate hydration; avoid drinking too much fluid in a short period. —Avoid alcohol, diuretics, caffeine, artificial sweeteners, spicy or acidic foods. —Avoid medications that cause urinary retention – antihistamines, decongestants, anti-cholinergic, anti-depressants —Post-TURP teaching: ◦Normal to feel the urge to void while the catheter is in place. ◦Do not void around the catheter to avoid bladder spasms. ◦Urine will be blood-tinged, can pass small clots for several days – increase fluid intake to at least 2-2.5 L daily (unless contraindicated). ◦Monitor for infection and incontinence. ◦Reproduction ability should not be affected. ◦Report severe spasm and decreased urinary output → possible obstruction —Signs and symptoms of acute urinary retention

Question 46

What is erectile dysfunction?

Answer 46

—Inability to achieve or maintain an erection for sexual intercourse. —May be organic (gradual deterioration of function) or functional (rapid onset, usually have normal nighttime and morning erections, follows a period of high stress). —Has a strong correlation with hypertension and BPH and spinal issues —Medications- most common intervention for ED ▪ Phosphodiesterase-5 inhibitors (PDE-5) – relaxes the smooth muscle in corpora cavernosa –box) table 67.4 page 1488

Question 47

What are the three ways that erectile dysfunction can be managed?

Answer 47

1. Pharmacologic agents 1. oral meds (sildenafil) 1. side effects: HA, flushing, dyspepsia 2. Caution with retinopathy 3. contraindicated with nitrate use 2. Injected vasoactive agents 1. Complications include priapism (persistent abnormal erection) 3. urethral suppository 2. Penile implants 3. Negative pressure devices - vacuum

Question 49

What medications causes urinary retention?

Answer 49

antihistamines, decongestants, anti-cholinergic, anti-depressants

Question 50

What is urolithiasis?

Answer 50

Urinary calculus