adult health 2 exam 1

urinary incontinence

-involuntary loss of urine severe enough to cause social or hygienic problems

-causes aren’t part of urinary tract

-NOT a normal part of aging

-NOT a normal post-partum effect

stress incontinence

-inability to retain urine

-common in younger women (preg/birth)

-laughs, coughs, sneezes (STRESS)

-can’t close urethra NATURALLY

urge incontinence

-loss of urine for no reason

-no cues until they NEED to go

-older women (may be d/t nerves)

-no feeling of bladder “fullness”

overflow incontinence

-bladder reaches max capacity causing urine leakage

-d/t bladder muscle NOT CONTRACTING

-does not allow bladder to empty

-trickles out to avoid bursting

functional incontinence

-result of other factors

-don’t REMEMBER/FEEL (dementia, spinal)

-PT has disease/injury not related to urinary system

etiology and genetic risk for urinary incontinence

TEMPORARY: constipation, urinary stones, chemo/radiation, drugs

PERMANENT: spinal cord injury, brain/neuro disorder, surgery

incidence and prevalence

-as many as 60% of women over 65 report this condition (shorter urethra, birth)

risk for urinary incontinence increases with…

-chronic conditions

-vaginal deliveries

-pelvic prolapse

-prostate problems

-diabetes

-heart failure (excess fluids, diuretics)

-obesity

history for urinary incontinence

-often unreported (embarrassing)

-use effective screening methods

physical assessment for urinary incontinence

-assess abdomen (putting pressure/distention, bowel sounds/impaction, constipation=PRESSURE)

-inspect females for prolapse (weakened pelvic floor muscles)

-evaluate force and character of urine stream (trickle vs. strong stream, can/can’t stop stream)

-HCP will perform Digital Rectal Exam (feel for enlarged prostate)

psychosocial assessment for urinary incontinence

embarrassed/ashamed

lab assessment for urinary incontinence

-urinalysis (clean catch)

WBC: UTI

BLOOD: stones, UTI, trauma, cancer

GLUCOSE: DM

PROTEIN: kidney damage

bladder scan for urinary incontinence

-shows how much urine is in bladder

POST-VOID RESIDUAL: PT goes pee, scan for how much is left

voiding cystourethrogram (VCUG)

x-ray of urinary system, looks for urinary BACKFLOW

electromyography (EMG) of pelvic muscles

study of muscles in pelvis (can they contract/relax)

CT of kidneys and ureters

structural issues

nonsurgical management for urinary incontinence

NUTRITION: avoid taking in fluid before bed, going in public, etc (STAY HYDRATED)

DRUG THERAPY:

-anticholinergics: oxybutynin (decrease involuntary contractions, stops spasms, FOR URGE)

-beta-adrenergic agonist: mirabegron (urge incontinence, relaxes muscles, fills bladder all the way)

nonsurgical management for urinary incontinence (devices)

-penile clamps (blocks urine flow)

-pessary devices (inserted UP vag, holds things in place, in for 1mo, wash, put it back)

-vaginal cone therapy (weights, helps with pelvic floor muscle, 15mins 2x/day)

-external catheters (condom catheter, purewick)

behavioral interventions for urinary incontinence

-pelvic muscle therapy (which muscles to contract/relax)

-behavioral interventions (setting timers Q30mins, 45, etc)

surgical management (urinary incontinence)

-sling/suspension: mesh tape around urethra, pulls things UP (good for stress incontinence)

PREOP: educate

POSTOP: catheter @ home for 24hrs, take out

-management of urinary catheter (preventing CAUTI’s)

maintaining tissue integrity

-risk for incontinence associated dermatitis

-avoid feminine pads and depends (hold liquid on skin)

-prefer CHUCK pads

-bed-bound PT’s → supra-pubic catheter

home-care management for urinary incontinence

-no barriers to BR (stairs) → give urinals, commodes, etc

self-management education for urinary incontinence

-ID type of incontinence (stres: PF therapy, etc), diet changes

national association of continence

increase quality of life

american urological association

provide resources monetary resources

cystitis

-inflammatory condition of the bladder (NOT A UTI)

-usually refers to inflammation from infection

-irritants can cause cystitis without infection (chemo, radiation, feminine hygiene spray)

urinary tract infections (UTI’s)

-an infection that occur in any area of the urinary tract and the kidneys

acute UTI

bacteria in urinary tract

recurrent UTI

>2 infections in 6mo

>3 infections in 1yr

uncomplicated UTI

-no functional/anatomical

-not peeing post-sex, wiping wrong

complicated UTI

DM, pregnancy, obstructions

etiology and genetic risk for UTI

-E. coli/candida are the most causative organisms

-infectious vs. non-infectious cystitis (chemical exposure)

-catheters are most common factor associated with new onset UTI in hospital and long-term care (CAUTI)→ clean Q8H, hang below bladder

-interstitial cystitis (separate dx: chronic inflammation/autoimmune, of lower urinary tract)

incidence and prevalence for UTI

-UTI is a leading cause of primary care visits

-5th most common health-care associated infection

health promotion and maintenance for UTI

-sterile technique when inserting catheters

-clean technique when using intermittent catheters at home (single-use catheter recommended for home settings)

-National Patient Safety Goal (NPSG)- CAUTI prevention/HOUDINI

-increase fluid intake (dehydration leads to infection)

HOUDINI

H- hematuria

O- obstruction

U- urinary surgery

D- decubitus ulcer

I- intake/output

N- nursing end of life care

I- immobility

physical assessment for UTI

-assess catheter, VS, lower abdomen, bladder palpation

hallmark symptoms for UTI

dysuria, frequency, and urgency

other symptoms for UTI

fever, chills, nausea (older adults: CONFUSION)

lab assessment for UTI

-clean catch urine specimen

-urinalysis

-culture and sensitivity (before ABX, tells us what type of ABX to use)

-CBC/WBC (SEPSIS)

other diagnostic assessment for UTI

-pelvic ultrasound (obstruction, stones)

-voiding cystourethrography (fill bladder with fluid, watch as bladder empties/structural issues)

-cystoscopy (going in & looking @ bladder/ureters, can place a stent if necessary

drug therapy for cystitis

-fluconazole (fungal infections)

-nitrofurantoin/macrobid, trimethoprim/sulfamethoxazole/bactrim (dual fxn ABX, 7-14days)

-fluid intake

-comfort measures

-sitz baths 2-3x/day for 20 mins

surgical management of cystitis

-treats condition that increases risk for recurrent UTI’s

example: cystoscopy (placing stent, cauterize lesions, etc)

home-care MGMT for cystitis

finish ABX, front-back wiping, pee before/after sex

self-MGMT education

how to take drugs, urine assessments, etc

urolithiasis

-presence of calculi (stones) in urinary tract

-nephrolithiasis: kidney calculi

-ureterolithiasis: ureter calculi

-most common associated condition is DEHYDRATION

(no symptoms until in lower urinary tract)

etiology and genetic risk

-metabolic risk factors (dehydration)

-family history, obesity, diabetes, gout increase risk

-diet (increased sodium)

-higher risk for men (d/t diet/protein intake)

incidence and prevalence for urolithiasis

-varies with geographic location, race, family hx

-about 19% of males and 9% of females will have at least one episode

-increase risk for recurrence if no changes are made

history for urolithiasis

-family or personal hx

-diet hx

physical assessment for urolithiasis

-severe, sudden unbearable pain (renal colic→ urine backup, N/V, light-headed, high risk for infection)

-urinary obstruction=MEDICAL EMERGENCY, can impair urinary function

-oliguria/anuria

lab assessment for urolithiasis

-urinalysis

-CBC/WBC

imaging assessment for urolithiasis

CT of the abdomen/pelvis (will show stone/s)

non-surgical MGMT for urolithiasis

-strain urine

-lithotripsy (laser/sound waves, breaks apart stones for passing)

drug therapy for urolithiasis

-used in the FIRST 24-36 HRS WHEN PAIN IS MOST SEVERE

-NSAID’s

-opioids (SEVERE PAIN)
-spasmolytic (oxybutinin)

MINIMAL surgical MGMT for urolithasis

-ureterscopy (small tube and stent in ureter, repeat stones)

-percutaneous ureterlithotomy or percutaneous nephrolithotomy

POST-OP: monitor for bleeding, nephrostomy tube MGMT

open procedures for urolithiasis

-open ureterolithotomy/pyelolithotomy/nephrolithotomy

POST-OP: monitor bleeding, fluid intake

preventing infection (urolithiasis)

-less red meats (gout/purines)

-increase fluids (3L/day), I/O’s, diuretics (less Na)

preventing obstruction (urolithiasis)

#1 OPTION: DRINK LOTS OF FLUID!!!

-fluid intake

-drug therapy (ABX)

-ambulation

benign prostatic hyperplasia (BPH)

-glandular units in the prostate undergo nodular tissue hyperplasia

-can be benign or cancerous

-prostate grows larger as men age

-bladder outlet obstruction affects elimination CAUSING urinary retention, leakage, overflow incontinence, urinary backup

-hydroureter and hydronephrosis

BPH facts

-occurs in 50% of men between 51-60yrs old

-occurs in 80% of men >70yrs old

-EXACT CAUSE IS UNCLEAR

unmodifiable risk factors for BPH

-race, genetic susceptibility, family cancer hx

-get screened at approximate ages

modifiable risk factors for BPH

-obesity/metabolic syndrome, beverage consumption, physical activity

-caffeine, alcohol

history for BPH

-international prostate symptom score (I-PSS)

-elimination patterns

-hematuria

physical assessment for BPH

-digital rectal exam (DRE)

-completed by HCP

lab assessments for BPH

-prostate specific antigen (PSA), GOLD STANDARD DX, presents in blood (should NOT be in there)

-CBC (sepsis)

-BUN/creatinine (urinary backup)

-urinalysis and culture

psychosocial assessment for BPH

-frustration/depression

-embarrassment (dribbling/incontinence)

-libido affected

dx assessment for BPH

-transrectal ultrasound (US probe, view prostate through back)

-cystoscopy

-bladder ultrasound

improving urinary elimination (NON-SURGICAL)

-behavioral modification (decrease alcohol consumption)

-drug therapy (can have erectile effects)

-prostate artery embolization (decreased blood flow to prostate to keep it from getting bigger)

drugs for BPH

-alpha 1 andrenergic antagonists- TAMSULOSIN (flomax, relax smooth muscle in bladder)

-5-alpha-reductase inhibitors- FINASTERIDE (decrease size of prostate

MOSTLY GIVEN A COMBO DRUG!!

improving urinary elimination (surgical management)

-holmium laser enucleation of prostate (HoLEP)

-transurethral resection of the prostate (TURP)

-transurethral incision of the prostate (TUIP)

holmium laser enucleation of prostate (HoLEP)

scope in urethra and remove tissue that’s blocking flow

transurethral resection of the prostate (TURP)

-most common

-remove extra prostate tissue

POST-OP: continuous bladder irrigation (urine will be BRIGHT RED)

transurethral incision of the prostate (TUIP)

small cuts in prostate to decrease pressure on the urethra

home care MGMT for BPH

-possible urinary catheter at discharge

-increase fluid intake (2-2.5L/day)

self-MGMT for BPH

-TURP may cause temporary dribbling (let everything heal, symptoms should resolve)

-kegel exercises

healthcare resources for BPH

follow up with HCP as recommended

pyelonephritis

-bacterial infection→ starts in bladder and moves upward to infect kidneys

-acute (stones) vs. chronic (obstruction from injury, cancer)

-abscesses may develop (may need surgery)

common causes of pyelonephritis

-E. Coli

-enterococcus faecalis

-BACKFLOW OF URINE

process of pyelonephritis

-microbial invasion of renal pelvis

-inflammatory response

-resulting fibrosis (scar tissue)

-decreased tubular resorption and secretion

-impaired kidney function

history for pyelonephritis

ask about prior conditions (pregnancy: treatment is different)

physical assessment for pyelonephritis

ACUTE: flank pain, costovertebral angle tenderness (between ribs and vertebrae)

CHRONIC: less dramatic presentation, but similar symptoms (body gets used to it, kidneys are scarred)

psychosocial assessment for pyelonephritis

embarrassment and shame

lab assessment for pyelonephritis

-urinalysis

-blood cultures

-WBC/ESR/CRP (immune and inflammatory response)

-BUN/Cr/GFR (kidney function)

imaging assessment for pyelonephritis

-KUB (kidneys, ureter, bladder scan)

-CT (shows any defects)

other dx assessments for pyelonephritis

-antibody-coated bacteria in urine

-radionuclide renal scan (put dye inside kidneys, shows how long it takes for them to filter)

non-surgical MGMT for pyelonephritis

-drug therapy-acetaminophen preferred (NSAIDs are nephrotoxic!!)

-catheter replacement (treat infection, no new catheter for around 2-3wks)

-nutrition therapy (adequate fluid)

surgical MGMT for pyelonephritis

-pyelolithotomy (removing stone/s)

-ureteroplasty (backup of urine, repair ureters)

-nephrectomy (kidney REMOVAL, last resort!!)

preventing chronic kidney disease (pyeloneph)

-ABX therapy (specific to condition/bacteria)

-BP control (HTN can damage BV’s)

-hydration

self-MGMT for pyelonephritis

post-op, nutrition, catheter care, symptoms of recurrence

healthcare resources for pyelonephritis

home-health nurse available

hydronephrosis and hydroureter

-problems of urine elimination with outflow obstruction

-hydronephrosis (kidneys enlarge)

-hydroureter (ureter enlarges)

-COMMON CAUSES: stones, tumors, etc)

-can cause permanent damage to kidneys

history for pyelonephritis

-kidney disorders

-urological disorders

physical assessment for pyelonephritis

-flank/abdominal pain, chills, fever, malaise

-inspect flanks

-palpate abdomen

-bladder scan

diagnostic testing for pyelonephritis

-urinalysis

-BUN/creatinine

-US/CT of the abdomen

urologic solutions for pyelonephritis

-cystoscopy

-retrograde urogram (dye in kidneys)

radiologic solutions for pyelonephritis

-nephrostomy (percutaneous/via incision)

-post-operative (educate, monitoring, etc)

acute kidney injury

rapid reduction in kidney function resulting in:

-failure to maintain waste elimination

-fluid and electrolyte imbalance (can’t excrete fluids)

-acid-base imbalance (poor perfusion d/t heart disease, HTN, drugs, etc)

acute kidney injury is defined by: MUST MEET 1 of 3

-increase in serum creatinine by ±0.3mg/dL or more within 24hrs (easiest, most commonly used, takes a long time)

-increase in serum creatinine 1.5x or more than baseline

-urine output less than 0.5mL/kg/hr for 6hrs (straight)

AKI risk factors

-older adults (some can bounce back to baseline)

-adults with chronic illnesses (HTN/DM→ microvascular damage)

-20% of hospitalized patients and 60% of patients in ICU develop AKI

-decreased perfusion (shock, hypotension, sepsis)

-damage to kidney tissue (pyelonephritis, nephrotoxic drugs)

-obstruction of urine outflow (BPH, UTI)

prerenal AKI

-caused by source outside of kidney

-perfusion issue, HF, HTN, shock)

intrarenal AKI

-occurs inside kidney

-HTN EMERGENCY, glomerular disease/nephritis, nephrotoxic drugs)