Week 10 elimination issues Flashcards
What are the 6 things nurses monitor for with someone with altered kidney function and why?
- Fluid balance - hemodynamic status influences kidney function & specific gravity/osmolality
- Serum BUN & creatinine - indicator of kidney function
- Serum K - kidneys process most K+ so too much = kidneys not doing well
- Acid base balance - increase in uric acid
- Pain - can lead to hypotension
- Signs of infection - kidney damage and possibly lead to sepsis / septic shock
Why is K+ high in someone with kidney issues?
90% of K+ is secreted through the kidneys. If Kidneys can’t manage the K then serum increases
What are the diagnostic tests for UTI?
- Urine culture (C&S)
- Urine analysis (nitrates, leukocytes, blood)
- Blood work (urea, creatinine, WBC)
- Xray
- CT (if severe)
What are the symptoms of complicated Cystitis?
- Fever
- Chills and rigor
- N&V
- Malaise
- Flank pain
- Costovertbral angle tenderness (on the back)
What are the top 3 classic symptoms of uncomplicated UTI?
- Frequency
- Urgency
- Dysuria
What are some common symptoms of UTI apart from frequency, urgency, Dysuria?
- Suprapubic pain/tenderness
- low back pain
- Nocturia
- Incontinence
- Hematuria
- Pyuria
- Bacteriuria
- Retention
- feel like can’t empty bladder
What symptoms do acute pyelonephritis and complicated cystitis share?
- Fever
- chills
- flank pain
- N&V
- Malaise
- Tender at costovertebral angle
What symptoms are unique to acute pyelonephritis and not seen in complicated cystitis?
- Tachycardia
- Tachypnea
- abdominal discomfort
- recent cystitis or treatment for UTI
In older adults, are changes in mental status and falls reliable predictors of UTI?
No - must fully assess with diagnostics
What is the thing that causes most UTIs in general?
E. Coli
What is the thing that causes most UTIs in geriatric care?
Foly catheters
What organ is involved in uncomplicated cystitis?
bladder invovlement only
What organs are involved in complicated cystitis?
More than the bladder - has travelled up
Who is classified as complicated cystitis automatically?
Pregnant
immunocompromised
people with a penis
Why do we encourage fluid intake with UTIs?
to maintain dilute urine unless UTI is in someone with fluid restriction
How much urine do we want to see?
1.5 L/day
7-12 voids per day
30ml/hr
How much fluid do we encourage someone with a UTI to drink?
2-3L per day
What do we teach patients so that they can prevent UTIs?
- Drink 2-3L water/day
- Sleep, rest, nutrition (immune support)
- Don’t use spermacides
- females - clean front to back
- females- avoid scented products of all kinds down there
- females - pee before and after intercourse
- don’t hold in your pee - release helps get rid of bacteria
- notify doc of burning, retention, increased frequency right away
When is surgery indicated for UTI?
- structural abnormality causing consistent UTI
What is the Drug therapy for uncomplicated UTI?
-Antipyretic (Acetaminophen)- fever
-Antispasmodic (Ditropan) – helps relax the bladder
-Antibiotics (Trimethoprim/sulfamethoxazole)- uncomplicated UTI
What is different regarding route of Antibiotic administration between uncomplicated UTI and complicated UTI?
uncomplicated = PO
complicated = IV
What is the drug therapy for complicated UTI?
Antipyretic (Acetaminophen)- fever
Antispasmodic (Ditropan) – helps relax the bladder
IV antibiotics/broadspectrum (complicated UTI)
How do we minimize hospital acquired infection through catheters?
1.Hand hygiene/aseptic technique
2.Assess need daily
3.Leave in place only as long as it is indicated
4.Maintain a closed system
5.Obtain urine samples aseptically
What are the reasons a person might need a catheter?
-very close I&O incontinence accurate measurements
-ICU unstable patient
-hemodynamically unstable
-Unable to urinate
-Open wound no matter how much wound care we do that aren’t healing in that area
-some urologic procedures require it
What indicator helps us predict the likelihood of someone with an indwelling catheter getting a UTI in hospital?
amount of time it is in
- longer time = greater chance of UTI
When someone has a catheter, their chance of infection increases each day. What is the % of increased chance of infection?
3-10%
What are 3 main reasons for Urinary obstruction?
- Urolithiasis
- BPH
- Hydronephrosis/hydroureter
What is the most common cause of stone formation ?
dehydration
What are the 3 nursing priorities for someone with urolithiasis and why?
- Pain management - severe pain can = cause hypotension
- Infection prevention- don’t make it worse
- Urinary obstruction- emergency- can lead to damaged kidney function
What are the two most common symptoms of Urolithiasis?
- severe unbearable pain
- oliguria/anuria
What diagnostic tests are done for someone with Urolithiasis and why?
- urinalysis - 24 hr
- Urine specific gravity and osmolality - high = dehydration. Low = too much fluid (diluted)
- PH = type of stone
- Hematuria = stones damaging tissues
- WBC + bacteria = infection
- Cloudiness & odor - infection - Serum labs (blood work)
- WBC
- increased particles = contribute to stone formation ( calcium, phosphate, uric acid) - CT of abdomen/pelvis
- Ultrasound
What diagnostic test confirms stones?
CT scan of abdomen and pelvis
- if no CT- can do xray but not as good
- if preggers - can do ultrasound but not as good
do most stones pass with or without intervention?
Without
What medications are given to manage urolithiasis and why?
- Pain - Opioids, NSAIDS (careful with kidney impairment & bleeding folks)
- Overactive bladder - Oxybutynin
- Infection - antibiotics
- increase urine volume - thiazide diuretic
- decrease urine PH - Allopurinol
What are 2 things a patient can do to help manage their urolithiasis?
- Hydration (balance - not over/under hydrating)
- Walking - helps pass stone naturally
Why do we strain urine to catch stones?
because we want to obtain the stone to see what kind it is and then determine the cause of it
What is ECSL?
Lithotripsy (shock waves break up stones)
If a stent is placed in the ureter so that the fragments/stones can pass through without ruining the ureter, what 3 symptoms would we expect to occur ?
- some bruising
- some blood in urine after procedure
- some cramping
What are the 3 surgical interventions for urolithiasis?
- Ureteroscopy (endoscopic procedure)
- Percutaneous ureterolithotomy & percutaneous nephrolitotomy
- Open surgical procedure
What 3 interventions can be done via ureteroscopy?
- remove stones
- stent ureters
- lithotripsy - break up stones
What does a percutaneous ureterolithotomy & percutaneous nephrolithotomy do ?
removes stone in ureter or kidney
- go through the skin not through the urethra
Which surgical intervention for urolithiasis is a nephrostomy tube left in place?
Percutaneous ureterolithotomy & percutaneous nephrolithotomy
What 4 complications do we watch for post Percutaneous ureterolithotomy & percutaneous nephrolithotomy?
- bleeding
- nephrostomy tube - pink 24-48 hrs, then urine colour
- pneumothorax (lung collapse)
- S&S of inffection
What is open surgery for urolithiasis and when it is used?
- used when other methods have failed
- remove large, impacted stones
How often should a nephrostomy be flushed post-surgey?
possibly Q 8 hr
be careful and gentle - avoid infection
This intervention may require nephrostomy tube, ureteral stent, wound drain.
Open surgery for urolithiasis
What are 2 risk factors for BPH?
- male
- age (increases with age)
What two components of assessment are vital to assessing BPH and why?
- History - urinary issues/symptoms
- Physical- LUTS symptoms (lower urinary tract symptoms) - retention, leaking, incontinence
What 2 diagnostic methods are used to determine BPH?
- Digital rectal exam (DRE)
- Transrectal ultrasound (TRUS)
If symptoms aren’t too bad with BPH what is the first recommended intervention?
behaviour modification
- don’t drink before bed
- don’t drink lots at once
- limit alcohol and caffeine
Why should someone tell HCPs that they have BPH?
b/c some meds can cause worse urinary retention and increase symptoms
If BPH symptoms become bothersome, what is the first line of action ?
Drug therapy
1. Tamsulosin - Alpha-adrenergic antagonist
2. Finasteride & Dutasteride) - 5 alpha-reductase inhibitors
What is the FIRST intervention if BPH symptoms are bothersome and ACUTE?
Catheterization
What are the 3 minimally invasive procedures for BPH?
- prostate artery embolization
- TUNA (transurethral needle ablation)
- TUMT (transurethral microwave therapy)
What does Prostate artery embolization do?
-small catheter into groin
- reduces blood flow to prostrate
- shrinks prostrate
What does TUNA (transurethral needle ablation) do?
- low frequency energy
- shrink prostrate
- post temporary catheter to help drain urine
- sometimes prophylactic antibiotics
What does TUMT (transurethral microwave therapy) do?
- microwave energy
- destroys some of the prostrate
- catheter
- takes several months to see results
What are the indications of surgery for BPH?
1.Acute urinary retention (AUR) d/t obstruction
2.Chronic urinary tract infections
3.Hematuria
4. Hydronephrosis (urine back up d/t outlet obstruction)
5. Persistent pain with decrease in urine flow
What is TURP (Transuretheral resection of the prostate) ?
- remove enlarge portion of prostrate through endoscope
- removes transition zone area of prostrate
- some damage to uretheral lining
What is the post-op care for TURP?
1.Pain
2.Manage continuous bladder irrigation (CBI)
3. Clots/hematuria, output flow, bladder distention (CBI)
4. Ins & Outs
5.Bladder spasms
6.Risk for infection
7.Early ambulation
What kind of syringe do we use to irrigate a catheter of a CBI if there is no output?
60 cc to resolve clot
What do nurses do if the CBI isn’t flowing and irrigation doesn’t work right away or there is frank blood ?
Call the doc!
What is the goal with Hydronephrosis/Hydroureter intervention?
treat the cause of obstruction
What is nephrolithiasis?
stones in the kidney
What is ureterolithiasis?
stones in the ureter (tube from kidney to bladder)
What is BPH?
Enlarged prostate gland - can cause bladder outlet obstruction (BOO)
What is Hydronephrosis/hydroureter?
-enlargement of kidney (d/t back up) or ureter (d/t back up)
-happens because of outflow obstruction
ie) kidney stones, tumors, trauma
What 2 problems can Hydronephrosis/Hydroureter lead to if not treated in a timely manner?
- Kidney damage
- Necrosis
What are the 2 physical symptoms of Hydronephrosis/Hydroureter ?
- flank pain
- abdominal pain
What are the 3 imaging tests for Hydronephrosis/Hydroureter and why?
- PVR - bladder scan- how much urine is in there still
- CT - source of obstruction
- Ultrasound - source of obstruction
What labs are taken for Hydronephrosis/Hydroureter and why?
- Urine analysis (what’s in the urine)- infection, blood, WBC, etc
- Chem & CBC - b/c kidneys aren’t working and blood flow
What are the risk factors for bladder cancer?
- tobacco use
- exposure to gasoline and diesel fuels
- chemical exposure
What are the symptoms of bladder cancer?
- painless blood in the urine
- dysuria
- frequency
- urgency
What diagnostics are used for bladder cancer?
CT/MRI/US
cystoscopy (biopsy)
What risk factors are unique to Renal cancer compared to bladder cancer?
- exposure to heavy metals
- asbestos
What are the symptoms of renal cancer?
- flank pain - dull or aching
- blood in urine - LATE SIGN
What diagnostics are used for renal cancer?
CR/MRI/US
Cystoscopy (biopsy)
What is the risk factor for prostate cancer?
Advancing age
What is one diagnostic test unique to prostate cancer that Bladder cancer and renal cancer don’t have?
DRE - digital rectal exam
What are the early/late symptoms of Prostate cancer ?
early:
- bladder outlet obstruction
late:
- gross hematuria
- abdominal pain
What type of non-surgical chemo intervention is done in someone with Urothelial (bladder ) cancer?
Intravesical chemo (in the bladder)
- usually for 6 weeks, once a week
- chemo is drained before they go home
What do people who are undergoing intravesical chemo need to do at home?
- use separate toilet
- wash clothes in 10% bleach - ie undies to remove cytotoxic meds
What is Transurethral resection of the bladder tumor (TURBT) ?
-surgery to remove tumour
- early stage cancer
What is complete cystectomy/simple cystectomy/radical cystectomy ?
- Full removal of the bladder
- for more extensive cancers
What do people struggle with after a cystectomy?
Anxiety
body image
sexuality
b/c they don’t have a bladder - they have a permanent appliance
What is a Ureterostomy?
tube goes from kidney to uretostomy that sticks out of the skin
- need pouch for life
What is a conduit post bladder surgery?
- Ileal (Bricker’s) conduit - urine collected in part of intestine then comes out as a stoma
- Colon conduit - same thing
- needs pouch for life
What is a sigmoidostomy?
- urine is diverted to large intestine
- no stoma
- urine exits with feces
- bowel incontinence may happen
What is Ileal Reservoire (Kock’s pouch)?
-part of Intestine is made into a pouch that urine drains into
- person self- catheterizes through the stoma into the pouch
- bag not needed
What therapy is sometimes effective for bladder cancer (non-surgical)
Microwave therapy
What treatment that is typically used for cancer, is not as effective for renal cancer?
Chemo
What surgical intervention is used for Renal cancer?
Nephrectomy (removal of part of the kidney)
what 5 things must a nurse monitor post nephrectomy surgery in someone with renal cancer?
- Urine output - we want the remaining one still >30ml/hr
- Pain managment
- Hemorrhage - highly vascular area
- Adrenal gland insufficiency - b/c of proximity to kidney & surgery
- Infection
Post nephrectomy, what is the first sign of adrenal gland insufficiency/damage?
hypotention
What are the 4 interventions for Prostate cancer?
- Active surveillance - watch & wait
- Radiation therapy (external or internal)
- Drug therapy (chemo)
- surgery
What is the most common curative intervention of prostrate cancer?
Surgery
- often laparoscopic for localized cancer
- sometimes open surgery
Which type of cancer would we likely see PCA for pain post surgery?
Prostate cancer
What are 3 ways to decrease DVTs post prostate cancer surgery?
- Early mobilization (get up day 1)
- SCDs (the leg compression thingies)
- DB & C
What should someone avoid post prostate cancer surgery?
rectal procedures
- enemas
- prostate assessment
What should patients do post prostate cancer surgery with urinary incontinence?
Kegal exercises
what antibiotic is nephrotoxic?
Vancomycin
What is the most important thing we watch for in people with Kidney trauma?
hypovolemic shock
- are they bleeding?
- I&O
- hematuria
What do we watch for in the urine of people with kidney injury (trauma)?
Myoglobinuria
- Myoblobin d/t Rabdo
What type of fluid do we give with AKI typically?
Isotonic solution
1-3L
What are the next steps if there is no improvement in someone with AKI who has been given lasix?
Hemodialysis or ICU
What is someone with CKD at high risk for and why?
Fractures
Too much phosphate - kidneys can’t secrete well
What mineral should people with CKD avoid?
Magnesium
What should someone’s diet restrict when they have CKD and why?
- Na+ b/c of RAAS (will hold in Na+)
- K+ b/c not enough being secreted
- Phosphate b/c not enough being secreted
What are 2 psychosocial impacts of CKD on people?
- Fatigue
- Social impact - isolation, change, dialysis
Why would someone get CRRT?
(continuous renal replacement therapy)
1. don’t respond to lasix & are hemodynamically unstable still
2. can’t handle the lytes changes that come with regular dialysis
What are 2 main issues with Peritoneal Dialysis and why?
- Infection - b/c it goes right into the body
- Constipation - because it’s close to the colon
What are some hemodialysis indications in CKD?
- pulmonary edema
- severe uncontrollable hypertension
- hyperkalemia with ECG changes & symptomatic
- severe electrolyte or acid/base problems
- some overdoses
- Pericarditis
What are uremic symptoms?
N&V
Confusion
seizure
severe bleeding from platelet dysfunction
What is a complication of renal disesase?
severe bleeding from platelet dysfunction
When do we weigh a dialysis patient?
before and after hemodialysis
Will we see decrease or increase in BP after dialysis?
Decrease BP
Why do people on dialysis sometimes get muscle cramps?
extremem fluid shifts
What is disequilibrium syndrome?
- rapid removal of filtrates and fluids
- confusion
- N&V
- headache
- restlessness
How do we lessen disequalibrian syndrome?
-slow the rate of dialysis
- give meds after the treatment
