Week 6: Elimination Conditions Flashcards
What are UTI’s?
Common bacterial infections
What is an upper UTI?
Involves kidneys (Pyelonephritis)
What is lower UTI?
Involves bladder (Cystitis) or urethra (Urethritis)
What kind of procedure can introduce bacteria into the bladder?
Catheterization
What gender is more prone to UTI’s?
Females due to having a shorter urethra
What are predisposing factors for UTIs?
Renal scarring from persistent infections
Diminished urethral peristalsis: reduced mobility causing urinary stasis
Compression against ureters: obstruction of urine flow
What can elevate UTI susceptibility?
Abnormal urine flow and compromised immune systems
What is reflux?
Backflow of urine into the kidneys
What can cause immune deficiencies?
Older age, HIV, or chemotherapy
What conditions or defects can increase the risk of UTIs?
Neurogenic bladder (impaired bladder emptying due to spinal injury)
Congenital defects
Diabetes as high blood sugar provides a great area for bacteria
What common pathogen causes UTI’s?
E.coli and its prevalent in stool
How do some antibiotics increase the risk of UTI?
It weakens the immune system or alters the microbial environment
Recurrent antibiotics promote growth of pathogens
What are clinical manifestations of UTIs?
Abdominal discomfort
Dysuria (painful urination)
Constant urge to urinate
Hematuria (blood in urine)
What are 3 tests that can confirm a UTI?
- Urine for routine and microscopy
(examines urine under microscope for pathological elements) - Urine for culture and sensitivity
(Identifies specific bacteria and its antibiotic susceptibility) - Mid stream urine collection
(Collects midstream portion of urine)
What antibiotics are used to treat a UTI?
Sulfa drugs
Nitrofurantoin
Cipro or Levaquin (older adults)
In what ways can you prevent UTIs?
Hydrate to flush out bacteria
Frequent toileting
Wiping front to back
Prevent constipation as it puts pressure on the bladder
What is acute pyelonephritis?
Kidney infection that occurs when bacteria travels up to the kidneys causing pain and inflammation
What causes acute pyelonephritis?
Bacterial infection or obstructions (tumours, constipation, or pregnancy) if they stop urine flow
What are the clinical manifestations of pyelonephritis?
Fatigue
Sudden chills/fever
Vomiting
Flank Pain
Malaise (weakness)
What is flank pain?
pain between lower ribs and hips on the side of the body
What is included in the subjective assessment for diagnosing pyelonephritis?
Identifying the risk factors
What is included in the objective assessment for diagnosing pyelonephritis?
Flank pain or CV tenderness
In the objective assessment for diagnosing pyelonephritis, how do you assess for CV tenderness?
Place non dominant hand on rib cage and tap it with a fist (indirect percussion) if pt reports sharp pain it indicates pyelonephritis
What other tests should you do when diagnosing pyelonephritis?
WBC count
Urine test for culture and sensitivity
Intravenous Pyelogram IVP (Injects radioplaque dye to visualize urinary tract)
CT scan
What is important to remember regarding IVP?
Patient must be well hydrated after this procedure
What medication will treat pyelonephritis?
Antibiotics (Ampicillin, Vancomycin, Cipro, and Septra)
NSAIDS will decrease inflammation
Antipyretics to reduce fever and pain
What is another way of treating pyelonephritis without meds?
Ensuring pt is well hydrated to help flush out kidneys
What should you do if antibiotics don’t work will attempting to treat pyelonephritis?
Look at culture results, ensure antibiotic sensitivity matches the identified organism, adjust if needed
What is a urinary tract obstruction?
Any condition that blocks or impedes the flow of urine
What are the intrinsic causes of urinary tract obstruction?
Tumors
Diverticuli (sacs or weak spots)
Benign growths
Inflammation
What are extrinsic causes of urinary tract obstruction?
Tumors and adhesions
What are possible other causes of urinary tract obstruction?
Prostsate enlargement and Prolapsed uterus
What is Urolitiasis?
Kidney stones
What different compounds can make up kidney stones?
Calcium (most common)
Magnesium
Ammonia
Phosphate
What are the risk factors of kidney stones?
Family history, heat exposure, dehydration and immobility
How does immobility contribute to kidney stone formation?
reduces gravity assisted flushing of the kidneys
What 3 tests can be done to diagnose kidney stones?
Urine tests (look for blood & crystals)
IVP injection (loos for obstruction)
Cytoscopy (directly examines bladder using a small camera and light, done in OR)
Why are kidney stones so painful?
The stone has jagged edges that tear the ureter and cause spasms
How can we remove the stones?
Hydration helps pass the stones
Urine straining uses a mesh to filter the urine
Lipotripsy uses ultrasonic waves to break up the stones for easier passage, done in x-ray department
What are the 4 types of kidney stones that need dietary modifications?
Purine: Avoid sardines, mussels
Protein: Have moderate intake of protein
Calcium: Avoid dairy products
Oxalate: Limit spinach, asparagus and tomatoes
Where does kidney cancer arise from?
Cortex or pelvis
Are the tumors in kidney cancer benign or malignant?
can be either but malignant is more common
What is the most common type of Kidney cancer?
Renal cell carcinoma (adenocarcinoma)
What are the risk factors for kidney cancer?
Most significant is smoking
Others include obesity, exposure to chemicals and analgesic use
What are the S&S of kidney cancer?
Weight loss, weakness and anemia
What are the S&S of kidney cancer as it progresses?
Hematuria, severe flank pain, parable masses
How is most at risk for kidney cancer?
People with end stage renal kidney disease
When evaluating urinary incontinence and retention, what should the detailed history include?
The onset
Factors that worsen it
Record of voiding habits
Is the incontinence due to another cause such as UTI
When evaluating urinary incontinence and retention, what should the physical exam include?
General health
Usual urinary function
Mobility
Cognitive function
Rashes or skin breakdown in abdominal or pelvis area
Consider conditions affecting the nerves such as a spinal injury
What should be included in health teaching for urinary incontinence?
Maintain regular but flexible voiding schedule
Retrain bladder by assisting pt to bathroom every 2 hours
Avoid Constipation (Increase fibre, use stool softeners or laxatives)
Adequate fluid intake
Encourage mobility
What is urinary retention?
A medical emergency requiring prompt assessments, recognition and bladder damage
What causes urinary retention?
Urethral infections causing inflammation
Stones/other obstructions
Medications
Epidural anesthesia
What assessments should be done regarding urinary retention?
Bladder scan and inquire about voiding habits/feeling of empty bladder
What complication may happen in regards to urinary retention?
Bladder may rupture due to overdistention
What is a nephrostomy?
Fine catheter inserted on a temporary basis to preserve renal function when a complete obstruction of the ureter is present
How is a nephrostomy inserted?
Directly into the kidney and attached to a connecting tube for closed drainage
Using sterile asepsis, never clamped, and well secured
What should you look out for if pt complains about pain with their nephrostomy?
Check patency
Can be irrigated under strict asepsis with 5ml of NS
What is a rubber catheter?
Used for intermittent catheterization for residual urine
What is a foley catheter?
Left in for continuous drainage
What is a suprapubic catheter?
Inserted directly into the bladder through the abdomen, and used in pts with or without urethral opening
What is benign prostatic hypertrophy?
Enlargement of prostate gland due to an increased number of epithelial cells
What gender is BPH common in?
Older men
What is a common myth regarding BPH?
That it leads to prostate cancer
IT DOES NOT
How is BPH diagnosed?
Using a digital rectal exam, it estimates the size, symmetry and consistency of the prostate
What is the difference in the prostate in BPH and prostate cancer?
In BPH, prostate is smooth, firm, and symmetrical
In prostate cancer, prostate is irregular and not smooth
How is BPH treated?
Surgically, the procedure is called transurethral resection of the prostate (TURP)
What happens during TURP?
The prostate tissue is removed in small slices using a scope that is inserted through the urethra
Its performed under spinal or general anesthesia and no external incisions are required
What happens after TURP in regards to catheterization?
A 3 way foley catheter with a 30ml balloon is inserted to apply pressure on the prostate
1 port is used for irrigation, 1 for drainage.
How is the 3 way catheter secured after TURP?
Taped to pts inner thigh to maintain traction (traction cannot be released without doctors order)
What is important about the irrigation for the 3 way catheter after TURP?
Irrigation is run wide open to clear urine and potential clots
Hourly intake and output totals is crucial due to rapid infusion rates
As urine clears (over 24-48 hours) irrigation rate is gradually reduced
What are the complications of TURP?
Bleeding
Clot retention
Bladder spasm
Hypoatremia
How do we as nurses prevent bleeding complication after TURP?
Maintain adequate irrigation flow to prevent clot formation
How does the complication of clot retention occur for TURP?
Bladder spasms occur as the bladder attempts to expel clots
If a clot forms, a new catheter cannot be inserted outside of the OR
How can we treat the complication of bladder spasms for TURP?
Administer Opium and Belladonna to relax the bladder
Why is hypoantremia a complication of TURP?
Due to large volumes of irrigation fluid that decrease sodium levels
Must monitor sodium levels
When should aspirin or warfarin be stopped before TURP and why?
Aspirin should be stopped 4 days in advance
Warfarin should be stopped well in advance
They both cause a higher risk for bleeding
What is Radical Prostatectomy? Why would it be necessary?
Complete removal of prostate gland
Necessary when prostate is too large for TURP
What are the 3 approaches that can be done with a radical prostatectomy
Suprapubic
Perineal
Laparoscopic/robotic assisted
Suprapubic Approach - radical prostatectomy
A low midline abdominal incision
Used in cases of cancer to allow lymph node dissection
Perineal Approach - radical prostatectomy
Incision made between scrotum and anus
Does not allow for lymph node removal
Laparoscopic/robotic assisted
More recent, minimally invasive approach
For radical prostatectomy how long is a Foley catheter put in place?
1-2 weeks
What other kind of catheter can be used for radical prostatectomy? What else may be there?
suprapubic catheter
Surgical drain
How is urinary output calculated for radical prostatectomy?
by adding output from both suprapubic and urethral catheter
How long is the hospital stay after radical prostatectomy?
usually 3-4 days for a suprapubic approach
Which approach has a higher risk for infection and why?
Perineal because of the incisions proximity to the anus
Requires carful dressing change and monitoring after bowel movements
What complications happens after radical prostatectomy that involves their sexual function?
Erectile dysfunction due to damage to the nerves during surgery
Incidence depends on age and sexual function before surgery
What is the most common type of complication after radical prostatectomy?
Urinary incontinence in the months following surgery
Happens due to bladder being reattached
Kegel exercises will help strengthen the urinary sphincter
What complication happens due to prolonged bedrest after radical prostatectomy?
DVT and PE this why pts require DVT prophylaxis such as subQ heparin , enxoparin and gut protection
With a suprapubic approach for radical prostatectomy how long does pt stay in ICU?
Typically 24 hours to control bleeding
What is the goal of stoma care?
To prevent skin breakdown and ensure a good fit for the ostomy appliance
What are the ideal stoma characteristics?
Symmetrical
Intact skin around stoma
Healthy pink red skin
Flat configuration in upright and supine position
Protrusion of 1-1.5cm from abdomen
What are complications of a stoma?
Skin breakdown and irritation due to indentations, scarring and ammonia
Retracted stoma (funnels inward)
What causes ammonia crusting around the stoma?
Urine irritating the skin around the stoma
Why is a retracted stoma bad?
It causes pooling of urine which leads to further skin breakdown
What is acute kidney injury?
A sudden decline in kidney function, usually temporary
When are the kidneys susceptible to injury?
From reduced BP and hypovalemia
Why does reduced perfusion happen in the kidneys?
Because the brain and heart receive priority for cardiac output making the kidneys more vulnerable
What are the 3 types of acute kidney injury??
Pre-renal (caused by factors that reduce blood flow to kidneys) (dehydration)
Intra-renal (caused by direct damage to nephrons) (IV contrast dye)
Post-renal (Caused by obstruction of urine flow)
What is acute tubular necrosis in acute kidney injury?
Damage or destruction of the tubules due to lack of blood flow, toxic chemicals, or obstruction
Kidneys will appear pale and swollen
What is the urea and creatinine ratio in acute kidney injury?
Blood test to determine the cause of kidney problems
Ratio is usually 20:1
Disparencies may indicate lab errors or specific underlying issues
How can acute kidney injury be reversed?
By improving kidney perfusion stopping offending meds, and relieve obstructions
What is chronic kidney disease?
Develops slowly over many years
Often associated with diabetes
Progressive and nonreversible
What test indicates chronic kidney disease?
Glomerular filtration rates less than 60 for 3 months
What are the clinical manifestations of acute kidney injury?
Urinary changes (low output/oliguria and proteinuria)
Retention of fluids
Risk of bleeding
Waste product accumulation leading to neurological disorders
Electrolyte imbalances
What electrolyte imbalances happen in acute kidney injury?
Metabolic acidosis (kidney fails to excrete acids)
Hyperatremia due to water retention
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
What is included in the initiation phase of acute kidney injury?
Increase in BUN and Creatinine levels
Decreases urinary output
What is included in the maintenance (Oliguric) phase of acute kidney injury?
lasts 10-14 days or longer
May become anuric or oliguric (output less than 400 ml/24 hours)
Vitamin D supplement is needed
Hypocalcemia occurs in this phase
What is included in the recovery (diuretic) phase of acute kidney injury?
When BUN, creatinine and GFR are normal again
Output increases to 1-3L/day
Risk of hypovalemia and hypotension due to excessive fluid loss
Electrolytes return to normal
Full recovery can take up to 12 months
Why should fluids be restricted in acute kidney injury?
Because kidneys cannot excrete excess fluid
What are the nutritional needs for acute kidney injury?
Adequate protein intake, carefully monitored
Avoid food high is potassium and phosphate
Monitor sodium levels
What is normal potassium range, and what helps treat high levels?
3.5-5 mEq/L
Kayexalate is a cation that binds to potassium in the intestine facilitating excretion
What is important about aging kidneys?
less able to compensate for changes in volume, solute load, and cardiac output
What are clinical manifestations on chronic kidney disease?
Hypertension, HF, CAD, Pericarditis
Thyroid abnormalities
Hyperlipidemia
anemia, bleeding tendencies
Fatigue
Pallor, edema and itchy skin
What are S&S of kidney failure from buildup of waste products and excessive fluid?
Increased creatinine and BUN
Abnormal electrolytes
Acidosis
Anemia
Nausea
Foggy thinking
Pruitus (itchy)
Nerve damage
What are the nutritional needs for chronic kidney disease?
Protein restriction to reduce workload on kidneys
Restrict sodium, fluid, potassium, and phosphate
What are medications used to help with chronic kidney disease?
Kayexalate treats hyperkalemia
Beta blockers manage hypertension
Epoetin alfa treats chronic anemia (IM injection weekly)
Statins manage hyperlipidemia
What is peritoneal dialysis?
Removes waste products from blood by using the peritoneum in abdomen as a natural filter
For peritoneal dialysis where is the catheter placed and what solution is introduced?
Placed in the abdomen and dialysate is introduced to draw out toxins
What does Peritoneal dialysis help reduce
The need for hemodialysis as it can be done at home
What is the procedure for peritoneal dialysis?
Dialysate has a high concentration and needs to be warmed to prevent hypothermia
It takes 20-30 mins for dialysate to be introduced
The length of time the fluid stays in the abdomen before being drained is 35 mins to an hour
The clamp is then left open to daring fluid into drainage bag
What is automated peritoneal dialysis
Uses machine to perform dialysis exchanges usually done at night while pt sleeps and can be done at home
It fills, dwells and drains the dialysate
What are the complications of peritoneal dialysis?
Infection at catheter site
Peritonitis (inflammation of peritoneum due to infection)
Abdominal pain if dialysate is running to fast or too cold
Fluid in belly affecting the lungs
Protein loss
What is hemodialysis?
More invasive, blood is circulated through a machine to remove toxins
In hemodialysis, where is access to bloodstream achieved through?
AV fistula: Direct connection between artery and a vein
AV graft: Uses gore tex to connect artery and vein
Central venous catheter: Used for temporary access
In hemodialysis, what is a thrill?
A vibration felt over a patent graft indicating good blood flow
In hemodialysis, how can we protect the site?
By ensuring no BP measurement, No blood draws and no IVs or meds administered on that arm
Why is it more difficult to place a double lumen catheter on the subclavian veins?
They carry a risk of causing a pneumothorax
What are double lumen catheters?
Used for dialysis and placed on right/left jugular or subclavian veins
What is extremely important regarding double lumen catheters?
Lines must be protected and well secured by suturing a tape
Only dialysis nurses can access these lines as they are heparinized
How does the hemodialysis procedure work?
Blood is drawn out from the arterial side, filtered to remove toxins, and then returned to the venous side
What are the complications of hemodialysis?
Hypotension due to large volume withdrawal
Muscle cramps due to electrolyte imbalances
Blood loss
Disequilibrium syndrome: rapid fluid and electrolyte changes
Kidney transplants are a common treatment for what disease?
End stage renal disease
What is not removed during a kidney transplant?
The functioning kidneys, resulting in some patients having 3 kidneys
Rejection is a complication of kidney transplant, why is it important?
Immunosupression prevents rejection but increases infection risk
What are other complications of kidney transplants?
Septic necrosis occurs in joints due to chronic steroid therapy
Peptic ulcer disease
Glucose intolerance and diabetes due to steroids
Cataracts and lipid problems
What should you educate the pt on regards to kidney transplants?
Get bone testing
Do weight bearing exercises
Quit smoking
