Tx. of GU and Renal Disease Flashcards
Obstructive incontinence?
Patient often has symptoms such as hesitance, straining, and dribbling.
GI drug anticholinergic?,
glaucoma, may worsen reflux (smooth muscle)
Lab for Uremia?
BUN / GFR
Mag. tx?
2 Grams IV over 4 hrs (can infuse fast for OB/GYN)
**used a lot in preg patients with pre-eclampsia
asthmatics cause anti - inflammatory effects - Mg is a good off label - 2 grams of Mg settles down the inflammation and cardia irritability (PVC’s and PAC’s)**
Additional UI tx?
Void at regular intervals starting with every 30 minutes, working up to every 3 to 4 hours
Kegel exercises in women
Drug treatment may not be very effective
Avoidance of caffeine, alcohol, artificial sweeteners
has to do with the acetyl choline receptor
What should not be consumed if taking metronidazole ?
Alcohol should not be consumed during therapy and for one day after completion of therapy (for oral or vaginal therapy)
**cant drink with it and it causes abdominal discomfort **
__alone does not cause dysuria, dyspareunia, pruritus, burning, or vaginal inflammation (erythema, edema)
BV
The presence of these symptoms suggests mixed vaginitis
symptoms due to other pathogens
Emergent treatment of hyperkalemia options?
Dextrose 50% IV - 1 amp of dextrose
Insulin IV - 10 units of regular insulin
Beta-2 agonist (albuterol)
Sodium bicarbonate IV (use Bicarb to move out K )
Sodium polystyrene sulfonate (Kayexalate)
Potassium class?
electrolytes
Magnesium Indications?
Hypomagnesemia
preeclampsia or eclampsia-assoc seizure
Tocolysis (Supress premature labor)
ventricular arrhythmias
torsades de pointes
severe asthma exacerbation, adjunct tx off label ( settles down PVC’s)
Isotonic saline and/or blood should be used in?
patients with blood loss.
BV: _________________ producing lactobacilli appear to be important in preventing overgrowth of the anaerobes normally present in the vaginal flora
Hydrogen-peroxide
Potassium MOA?
replaces potassium, a major intracellular cation involved in physiologic processes such as nerve impulse conduction, cardiac, skeletal, and smooth muscle contraction, and maintaining normal renal fxn
Hypotonic solutions should be used in __________.
hypernatremia
__________ seem to be as effective as other crystalloid solutions and colloid-containing solutions, and are much less expensive
Saline solutions
tolterodine (Detrol) is metabolized by?
liver
Crystalloid are for ?
volume expansion
thick stuff, in vascular expanders
The administration of ____________ in hyponatremic patients will initially tend to raise the serum sodium since it has a higher sodium concentration than the serum
isotonic saline
There are ____ agents available that block post-synaptics fibers of the ___ endings on detrusor muscle of bladder thus reducing spasmotic action on smooth muscle and reducing urge incontinence
six
PNS
Blood products or substitutes – includes ____________, blood substitutes
packed red cells
Amsel criteria for diagnosis of __
BV
Crystalloid solutions ?
Saline solutions
Ringer’s lactate,
bicarbonate buffered 0.45% saline
How can you lose soul free water?
Leads to an elevation in the serum sodium concentration
Skin loses (Runners, sun-bathers)
Gastrointestinal loses
Urinary loses
diabetes insipidus or an osmotic diuresis due to glucosuria in uncontrolled diabetes mellitus
Sodium overload (football salt tablets) / job poisoning
Hypokalemia tx dosage?
40 meq potassium chloride in 1000cc ( this is diluted) Normal saline over 2 hrs
_______________ has isotonic solution capable of reversing with free water correcting Na level
Simple normal saline
Dextrose 50% IV - 1 amp of dextrose facts?
1 amp or 50 cc of 50% glucose - pre loaded ampule
decrease K levels but not changing glucose
Potassium or bicarbonate may need to be added in patients with ?
hypokalemia or metabolic acidosis
** buffer it down if it is to acidic or basic **
Both crystalloids (eg, isotonic saline, Ringer’s lactate) and colloid-containing solutions have been used to replace the ___?
extracellular fluid deficit.
** Nl saline and C we want to drive fluid into the intracellular space **
Anyone with symptomatic BV infection should be _______
treated
phenazopyridine (Pyidium) side effects ?
Turns urine orange! Educate patient!
May discolor contact lenses
** my contacts are orange and urine is orange, this is more for uncomplicated cystitis etc. **
Some clinicians avoid use of metronidazole in the _________ because it crosses the placenta, and thus has a potential for teratogenicity.
first trimester
Hyponatremia: Raising the serum sodium by_____should generally alleviate symptoms and prevent herniation brain
4 to 6 meq/L
________ have a lot of incontinence but they all have a big risk for adverse effects when using the drugs to treat them
Alzheimers
Hypertonic Solution?
5% dextrose in 0.45 NaCl
10% dextrose in water (D10W)
**colloid - very thick infusion ( blood products) - we are looking for volume expansion so these are hypertonic - very viscouss fluids **
__________ may be less effective than the metronidazole regimens
Clinda
UI treatment?
Correct underlying problem (UTI, delirium, atrophic vaginitis, depression, restricted mobility, stool impaction, BPH)
Bacterial vaginosis (BV) Physical Exam?
women typically present with vaginal discharge and/or vaginal odor.
The discharge is off-white, thin, and homogeneous
Odor is an unpleasant “fishy smell” that may be more noticeable after sexual intercourse and during menses
Alternative Clindamycin dosages?
Alternative regimens include oral clindamycin (300 mg twice daily for seven days)
or
clindamycin ovules (100 mg intravaginally once daily for three days)
Sodium polystyrene sulfonate (Kayexalate) MOA?
Removes potassium by exchanging sodium ions for potassium ions in the intestine (especially the large intestine)
Oral or Rectal
Diarrhea!!!!!!!!!!!!!!!!!!!!!!!
Emergent treatment of hyperkalemia?
Patients with electrocardiographic changes
Patients with a serum potassium greater than 6.5 to 7 meq/L
some would not initiate such therapy until the serum potassium is ≥7 meq/L in patients who have no clinical or electrocardiographic signs of hyperkalemia
** sometimes dont rely on EKG cause some chronic patient .. this is were the normaly reside so they will not have EKG changes **
rule of 7
When do you want to treat hyperkalemia ?
Presence or absence of symptoms and signs associated with hyperkalemia
muscle weakness or paralysis
cardiac conduction abnormalities
peaked t-waves
**sometime they will be at 7 with no sxs. - they are prob a chronic renal patient **
Correction of hypernatremia requires the administration of dilute fluids to both ?
correct the water deficit and replace ongoing water losses
When appropriate, interventions to limit further water loss
_______________ saline should be used in hyponatremia
Isotonic or Hypertonic
Colloid-containing solutions
?
albumin solutions, hyper-oncotic starch, dextran, gelatin
Hypomagnesium means Mag. levels are below?
1.7
Infusing to fast to treat hyponatremia can cause?
Central pontine myelinolysis
Hypertonic = ?
D5 / 0.45 NaCl
10% Dextrose
increases solute conc.
tolterodine (Detrol) MOA?
antagonizes acetylcholine at muscarinic receptors
Relaxes bladder smooth muscle
Inhibits involuntary detrusor muscle contractions (anticholinergic)
BV treatment in pregnant women?
Oral treatment is effective and has not been associated with adverse fetal or obstetrical effects
BV treatment in pregnant women examples?
Metronidazole 500 mg orally twice daily for seven days
Metronidazole 250 mg orally three times daily for seven days with food
easier on the stomach
Clindamycin 300 mg orally twice daily for seven days
Goal of hypernatremia tx?
Goal of this regimen is to lower the serum sodium by 1 to 2 meq/L per hour and to restore normonatremia in less than 24 hours.
GO SLOW!!! 50-75 ml/hr
What is preferred over colloid-containing solutions for the management of patients with _____________ not due to bleeding.
Crystalloids
severe volume depletion
Addition BV tx?
Clindamycin
vaginal clindamycin cream is a reasonable therapeutic choice
**if you cant take flaygl cause the stomach issues etc then you can use this as an alternative but this is not the primary choice **
Meta-analysis has not found any relationship between ___________ exposure during the first trimester of pregnancy and birth defects
metronidazole
** for preg. more topical then oral **
Treatment of Incontinence:
Muscarinic receptor antagonists (MRA)
Muscarinic antagonists examples?
Oxybutynin (Detrol, Detrol LA, Oxytrol patch)
Tolterodine (Detrol)
more popular one
Solifenacin (VESIcare)
Trospium (Sanctura)
Darifenacin (Enablex)
Fesoterodine (Toviaz)
**if anything these guys are moderately working with incontinence - these drugs do not work that well
O and T have cross over thats why Detrol is listed for both**
Clinda BV dosage?
seven-day course of 2 percent clindamycin cream vaginally (5 grams of cream containing 100 mg of clindamycin phosphate)
Hypotonic solutions have an electrolyte content of ______________and are administered to expand the ____________.
less than 250 mEq/L
intracellular space
Normal Saline and D5NS (dextrose 5% in Normal Saline)
NL saline is to expand intracellular space, drive fluid into the cells ( into the cellular space)
Magnesium dosage forms?
IM; IV; INJ
What is Urinary incontinence (UI)?
Involuntary loss of urine severe enough to cause social or health problems
Potassium chloride can be given __ to patients who are unable to take oral therapy or as an adjunct to oral replacement
intravenously
**K infusion through IV is very painful cause it is acidic so maybe supplement it with some bicarb, it does burn through the IV **
Colloid = ?
Albumin blood products
LR (volume expanders)
Urge incontinence?
Patient has urge to urinate and can often maintain continence by running to bathroom.
Urinary Tract Analgesia
examples?
phenazopyridine (Pyridium)
great resource for dysuria
Hyponatremia is typically treated with ?
Typically treated with isotonic (0.9% NaCl) or hypertonic saline (0.45% NaCl)
Hypokalemia treatment considerations?
Painful
Add bicarb and/or lidocaine avoid burning of infusion
to avoid some of the burning but not to much bicarb cause we will change pH
PO dose 20 meq, 40 meq J-Dur daily
Repeat labs
Find source
Check Magnesium levels
**K-Dur, serial tract labs , find the source **
Muscarinic receptor antagonists (MRA) works by ?
Type of anticholinergic agent that blocks the activity of themuscarinicacetylcholine receptors (Ach)
Ach released from postganglionic fibers in the parasympathetic nervous system
Hypernatremia (hypernatremia that has been present for 48 hours or less)? Case study? tx?
5 percent dextrose in water, intravenously, at a rate of 3 to 6 mL/kg per hour
serum sodium and blood glucose should be monitored every one to two hours until the serum sodium is lowered below 145 meq/L
Hyponatremia / Hypokalemia tx?
Sodium and/or potassium can be added to the intravenous fluid
Addition of sodium and/or potassium decreases the amount of free water that is being given (more ions in soln)
**if they low on K then are probably low on Mg **
Amsel criteria?
Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
Vaginal pH >4.5
Positive whiff-amine test, defined as the presence of a fishy odor when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge
Clue cells on saline wet mount
“at least three criteria must be present”
Nonpregnant women BV treatment?
Metronidazole (Flagyl) or clindamycin (Cleocin) administered either orally or intravaginally (troche) results in a high rate of clinical cure (70 to 80 percent at four weeks of follow-up)
Oral medication is more convenient, but associated with a higher rate of systemic side effects than vaginal administration.
tolterodine (Detrol) is excreted in?
urine and feces
phenazopyridine (Pyidium) preg cat.?
B
More ions=?
less free water
Stress incontinence?
Any action that raises abdominal pressure, like sneezing, cough, laughing or standing, can cause immediate leakage.
phenazopyridine (Pyidium) indications?
dysuria
Mag. class?
Labor Suppression/Tocolytics
Antiarrhythmic
Parenteral; Advanced Life Support) (ACLS/PALS/NALS
Acute or hyperacute hyponatremia ?
Developed within the previous 24 hours
Called “acute”
There is an increased presence of UI in _______ patients cause?
dementia
loss of frontal lobe inhibitor
UI in dementia due to loss of frontal lobe inhibition with default to pure reliance on the brainstem for sympathetic and parasympathetic control of urination creates
dementia patient lose control of frontal lobe
Muscarinic antagonists
facts?
Not to be used in patients with cognitive impairment
Modestly more effective than placebo
Avoid in men bladder outlet obstruction
Hypotonic = ?
NS 0.9% NaCl
<250 mg/L solute
Treatment with a single oral dose of 2 grams of metronidazole has a ___________ and is no longer recommended for treatment of BV (CDC)
lower efficacy
** they dropped the 2 g dose **
Hyperkalemia is often a result from
impaired urinary potassium excretion
Acute or chronic kidney disease (CKD)
Common renal dialysis
Disorders or drugs that inhibit the renin-angiotensin-aldosterone axis
Commonly occurs in uncontrolled hyperglycemia
________________ has similar efficacy to seven days of oral metronidazole
multi-day vaginal gel
Bacterial vaginosis (BV) patho?
Complex change in the vaginal flora characterized by a reduction in concentration of the normally dominant hydrogen-peroxide producing lactobacilli
Increase in concentration of other organisms, especially anaerobic gram negative rods
Not an STD – Educate patient
**abnormal abundance of growth in the vag. , not a STD just an over abundance , make sure to screen for STD as well , lack of lactobacilli that causes an overabundance of overgrowth of bacteria **
Hypernatremia results from ?
Loss of solute-free water
Magnesium routes?
IV IM PO
tolterodine (Detrol) should not be used in patients with what ?
cognitive impairment Alzheimers (anticholinergic effects)
phenazopyridine (Pyidium) MOA?
produces topical analgesia
** AZO has angelsc effects at the end of the urethra - stops the burning **
Increase in serum sodium should not exceed ?
8 meq/L in any given 24-hour period
Hyponatremia: goal of emergency therapy is to rapidly increase the serum sodium by?
4 to 6 meq/L over a period of several hours
Hypokalemia tx?
Underlying cause of the hypokalemia should be identified
Potassium sparing diuretics?
Check Magnesium level
Patients with hypokalemia may also have hypomagnesemia due to concurrent loss with diarrhea or diuretic therapy
the origin of the problem could be from Mg but it manifesting in K ( low K then low Mg)
phenazopyridine (Pyidium) caution or contraindications?
Uremia (raised level in the blood of urea and other nitrogenous waste compounds)
glomerulonephritis
severe hepatitis (metabolized liver)
pyelonephritis during pregnancy
renal impairment
UTI ABS?
Quinolones
Sulfa
Macrobid
Cephalosporins
Who can develop hyponatremia ?
Developed over just a few
marathon runners
psychotic patients
Ecstasy
called “hyperacute.”
look at the time lapse when they have been losing the Na
most commonly used crystalloid fluid is?
normal saline,
a solution of sodium chloride at 0.9% concentration
There are ___________________ options for metronidazole vaginal gel for the treatment of BV
single and multi-day dosing
5 grams of gel contains ____ mg of metronidazole
37.5
Metronidazole (Flagyl) dosage?
500 mg twice daily for seven days
If potassium is added to the intravenous fluid, ______________ is present and a further adjustment to the rate of infusion must be made.
then less free water
Choice of replacement fluid
depends on?
largely dependent upon the type of fluid that has been lost and any concurrent electrolyte disorders
