Final Exam Study Guide (Adult II) Part 2

What is overflow incontinence and what might cause it?

Overflow leads to dribbling urine; incomplete emptying of bladder leads to distention and urine leakage

Causes:

1. Urethra prolapse

2. BPH

3. Weak bladder muscles (like w/ diabetic neuropathy and spinal cord injury)

For a male reporting urinary incontinence, what should the nurse ensure has been performed?

Ensure prostate exam performed

The leakage of urine occurs in small amounts and is more frequent when the patient coughs.

Which information does the nurse provide to the patient about the disorder?

“This is called stress incontinence”

• “This is caused by weakness of muscles around the urethra”

• “This occurs when intraabdominal pressure exceeds urethral resistance”

Elderly female patient experiencing urinary incontinence. Which physiological change does the nurse expect to see in this patient?

Decreased muscle tone

Explain the renin-angiotensin-aldosterone system

What is chronic kidney disease?

A progressive, irreversible disorder, and kidney function does not recover

—>In CKD, there is kidney damage or a decrease in glomerular filtration rate that lasts for 3 or more months

What does untreated chronic kidney disease lead to?

Untreated chronic kidney disease leads to end-stage renal disease (ESRD/ESKD), the retention of uremic waste products, and the need for renal replacement therapy or kidney transplantation

What are the 5 stages of chronic kidney disease based on?

Estimated glomerular filtration rate (GFR: the amount of plasma filtered through the glomeruli per unit of time.

List risk factors for chronic kidney disease

1. CV disease

2. Diabetes

3. HTN

4. Obesity

5. Glomerulonephritis

6. Pyelonephritis

7. Renal cancer

List s/s of chronic kidney disease

1. Lethargy

2. Seizures

3. Coma

4. HTN

5. Edema

6. Anemia

7. Muscle weakness

8. Muscle cramping

9. Metallic taste in mouth

10. Anorexia

11. N/V

12. Frost on skin (uremic frost)

13. Itching (pruritus)

14. Hiccups

What diagnostic labs/tests are used to evaluate a patient for chronic kidney disease?

1. Urine and serum lab tests

2. Kidney US or CT

List interventions for the management of chronic kidney disease.

Chronic kidney disease has a slow progression, so interventions include:

1. Control CV risk factors

2. Tx hyperglycemia

3. Manage anemia

4. Encourage smoking cessation

5. Weight loss (if obese)

6. Exercise

7. Reduce salt/alcohol intake

8. Education on minimizing nephrotoxins

9. Manage BP: Keep BP below 130/80

10. Early referral for initiation of renal replacement therapies

List pharmacologic interventions for the management of chronic kidney disease.

1. Calcium and phosphorus binders (OsCal, PhosLo, Renegel): To tx the calcium and phosphorous imbalance

2. Antihypertensive and CV Agents (Digoxin, Dobutamine, Diuretics): To tx HTN, HF, and pulmonary edema

3. Anticonvulsants: To tx neurologic abnormalities (Valium, Phytoin)

4. Erythropoietin (Epoetin Alfa): To tx anemia (we want hct of 33-38% and hgb of 12 g/dL); administered IV or subQ ; patients on erythropoietin will c/o of decreased levels of fatigue

5. Iron supplementation

What is acute nephritic syndrome?

A type of glomerulonephritis that causes inflammation of the glomerular capillaries

List risk factors for acute nephritic syndrome.

Recent infection, such as:

1. Acute viral infections (URIs, mumps, varicella, Epstein-Barr virus, Hep B, HIV)

2. Skin infection

3. Strep infection (of the throat)

4. Certain medications

List s/s of acute nephritic syndrome. Also list s/s of its more severe form, and s/s that could happen in older adults.

1. Hematuria

2. Edema

3. Proteinuria

4. Cola-colored urine

5. HTN

6. Anemia

7. Elevated BUN and creatinine (aka Azotemia—>high amount of nitrogen containing compounds in the blood like urea and creatinine)

More severe form:

1. HAs

2. Malaise

3. Flank pain

In Older Adults:

1. Dyspnea

2. Engorged neck veins

3. Cardiomegaly

4. Pulmonary edema

List diagnostic labs/testing to diagnose acute nephritic syndrome.

1. Serum lab tests—>elevated serum IgA level

2. Electron microscopy and immunofluorescent analysis to help identify the lesion

3. Kidney bx is needed for a definitive diagnosis

List interventions for the management of acute nephritic syndrome.

Management: Tx sx, preserve kidney function, and tx complications quickly (hypertensive encephalopathy, rapidly progressive glomerulonephritis, ESKD)

1. Corticosteroids (to control inflammation)

2. Antihypertensives (to control BP)

3. Antibiotic if the cause is strep A (penicillin)

4. Dietary restrictions (protein/sodium restriction)

What is nephrotic syndrome?

A disorder that occurs when renal and systemic diseases cause glomerular damage, which results in increased glomerular permeability to plasma proteins.

List causes of nephrotic syndrome

1. Massive proteinuria

2. Many kidney or systemic diseases that causes glomerular damage (i.e., diabetic neuropathy, lubpus, bacterial endocardidits)

List s/s of nephrotic syndrome.

1. Edema (usually pitting and/or periorbital, can also be sacral, abdominal, or in the legs/feet)

2. Irritability

3. HAs

4. Fatigue/Malaise

5. Proteinuria

6. Hypoalbuminemia

7. Hyperlipidemia

List diagnostic labs/tests to evaluate a patient for nephrotic syndrome.

1. Urine tests—>Proteinuria (especially high levels of albumin; levels >3.5 g/day)

2. Serum tests—>hypoalbuminemia (low blood albumin levels), hyperlipidemia (LDLs)

3. Kidney Bx necessary to confirm diagnosis

List interventions for the management of nephrotic syndrome.

Management is focused on addressing the underlying illness, slowing the progression of CKD, and relieving sx

1. Diuretics (to minimize edema)

2. ACE inhibitors (to reduce proteinuria)

3. Lipid-lowering agents (to tx hyperlipidemia—>statin meds)

4. Dietary sodium restrictions

What is acute kidney injury?

A rapid reduction in kidney function resulting in failure to maintain fluid-electrolyte and acid-base balances.

—>Can occur over a few hours or a few days

—>severity of AKI is based on increases in serum creatinine and decreased urine output

—>Severity of AKI is based on the RIFLE and KDIGO classification systems

List potential causes of acute kidney injury.

Prerenal Failure—>Caused by reduced kidney perfusion (hypoperfusion of the kidney)—>most common cause of AKI

1. Volume depletion resulting from: GI losses (emesis/diarrhea, NG suction), hemorrhage, renal losses (diuretic agents, osmotic diuresis)

2. Impaired cardiac efficiency resulting from: Arrhythmias, cardiogenic shock, HF, MI

3. Vasodilation resulting from: Anaphylaxis, antihypertensive meds/other meds that cause vasodilation, sepsis

Intrarenal Failure—>damage to kidney tissue/reflects injury to glomeruli, nephrons, and tubules

1. Prolonged renal ischemia resulting from: Hemoglobinuria (transfusion reaction, hemolytic anemia), pigment nephropathy (associated w/ breakdown of blood cells containing pigments that in turn occlude kidney structures), rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)

2. Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin), ACE inhibitors, heavy metals (lead, mercury), NSAIDs, radiopaque contrast agents, solvents/chemicals (ethylene glycol, carbon tetrachloride, arsenic)

3. Infectious processes such as: Acute glomerulonephritis, acute pyelonephritis

Postrenal Failure—>caused by obstruction to urine flow

1. Urinary tract obstruction, including:

• BPH

• Blood clots

• Calculi (stones)

• Strictures

• Tumors

List prerenal failure causes of AKI.

Prerenal Failure—>Caused by reduced kidney perfusion (hypoperfusion of the kidney)—>most common cause of AKI (so shock can cause prerenal failure/AKI)—>anything that causes massive fluid loss can cause prerenal failure

1. Volume depletion resulting from: GI losses (emesis/diarrhea, NG suction), hemorrhage, renal losses (diuretic agents, osmotic diuresis), severe burns

2. Impaired cardiac efficiency resulting from: Arrhythmias, cardiogenic shock, HF, MI

3. Vasodilation resulting from: Anaphylaxis, antihypertensive meds/other meds that cause vasodilation, sepsis

List intrarenal failure causes of AKI

Intrarenal Failure—>damage to kidney tissue/reflects injury to glomeruli, nephrons, and tubules

1. Prolonged renal ischemia resulting from: Hemoglobinuria (transfusion reaction, hemolytic anemia), pigment nephropathy (associated w/ breakdown of blood cells containing pigments that in turn occlude kidney structures), rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)

2. Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin), ACE inhibitors, heavy metals (lead, mercury), NSAIDs, radiopaque contrast agents, solvents/chemicals (ethylene glycol, carbon tetrachloride, arsenic)

3. Infectious processes such as: Acute glomerulonephritis, acute pyelonephritis

List postrenal failure causes of AKI

Postrenal Failure—>caused by obstruction to urine flow

Urinary tract obstruction, including:

• BPH

• Blood clots

• Calculi (stones)

• Strictures

• Tumors

List s/s of acute kidney injury.

1. Drowsiness

2. HA

3. Muscle twitching

4. Seizures

5. Increased BUN and creatinine (aka azotemia)—> significant increase in creatinine (especially if over a few hours or a couple days)

6. Oliguria (low urinary output; for adults urine output <400–500 mL/day or <0.5 mL/kg/hr)

7. Fluid overload

8. Dyspnea

9. Increased K+

10. Increased phosphorus

11. Decreased H&H

12. Decreased calcium

13. Increased magnesium

Differentiate prerenal failure, intrarenal failure, and post renal failure in the following characteristics:

1. Etiology

2. BUN value

3. Creatinine

4. Urine output

5. Urine sodium

6. Urinary sediment

7. Urine osmolality

8. Urine specific gravity

What pH crisis do patients with AKI experience?

Progressive metabolic acidosis

What is used in the diagnostic evaluation of acute kidney injury?

1. Serum blood tests

2. Urine tests

3. Imaging studies:  U/S, CT, KUB x-rays, kidney biopsy

List interventions for acute kidney injury.

1. Eliminate the underlying cause (Prerenal, Intrarenal, Postrenal)

2. Maintain fluid balance

3. Avoid fluid excess

4. RRT if indicated

5. Nutritional therapy—>low in sodium, potsssium, and phosphorus, but higher in calories than standard feedings

6. Medications: Diuretics (used to increase urinary output), Calcium-channel blockers (used to tx AKI resulting from nephrotoxins)

What is hemodialysis/what is done during this? What is the purpose of hemodialysis? How common is it and how often is it performed?

• Hemodialysis is a type of renal replacement therapy that removes medications or toxins from the blood, or for edema or hypertension that does not respond to other treatment

• In hemodialysis, the blood is diverted from the client to a machine via the use of a blood pump to the dialyzer, where toxins are filtered from the blood, and the cleansed blood is returned to the client

• Purpose of hemodialysis: Prevent death—>it does not compensate for the loss of metabolic kidney function

• Intermittent hemodialysis (HD) is the most common renal replacement therapy (usually 3 times a week for 3-5 hours)

Compare AKI and CKD in the following areas:

1. Onset

2. Reversibility

3. Primary goal

4. Mortality

Differentiate the pathophysiology and causes of AKI and CKD

Differentiate the clinical manifestations of AKI and CKD

During hemodialysis, what is removed from the blood and how is it removed?

1. Toxins and wastes in the blood are removed by diffusion (large molecules blocked by semipermeable membrane—>i.e., RBCs, proteins)

2. Excess fluid is removed from the blood by osmosis

3. Ultrafiltration also helps to remove fluid and achieve fluid balance

What is required to perform hemodialysis?

Vascular access via:

1. Arteriovenous fistula: Joining an artery to a vein in the forearm; has the longest use capability and is the best option for vascular access

2. Arteriovenous graft: created b/t an artery and vein if the patient’s vessels are unsuitable for an AV fistula (connects using synthetic tubing

3. Central venous catheter

In what patients is hemodialysis immediately indicated?

Dialysis immediately for patients with

1. Fluid overload not responding to diuretics

2. Symptomatic hyperkalemia

3. Calciphylaxis (thrombosis and skin necrosis)

4. Symptomatic toxin ingestion (drug overdose or poisoning)

List nursing interventions for a patient undergoing hemodialysis.

1. Promote pharmacologic therapy—>heparin is usually admin to keep blood from clotting while in the dialysis circuit

2. Promote nutritional and fluid therapy

3. Meet psychosocial needs

4. Promote home, community-based, and transitional care

5. Protect vascular access

6. Detect cardiac and respiratory complications

7. Control electrolyte levels

8. Manage pain and discomfort

9. Prevent infection

10. Monitor for symptoms of uremia (Uremia is a dangerous, life-threatening condition defined as the buildup of urea and other nitrogenous waste products in the blood caused by severely damaged kidneys)

Sx of uremia include:

• Extreme fatigue

• Loss of appetite

• N/V

• Difficulty concentrating

• HA

• Weight loss

• In advanced stages, confusion, coma, or seizures

What is uremia and list s/s.

Uremia is a dangerous, life-threatening condition defined as the buildup of urea and other nitrogenous waste products in the blood caused by severely damaged kidneys

Sx of uremia include:

• Extreme fatigue

• Loss of appetite

• N/V

• Difficulty concentrating

• HA

• Weight loss

• In advanced stages, confusion, coma, or seizures

What is peritoneal dialysis (PD)? Where is the catheter placed? How is it different from HD?

• A type of renal replacement therapy

• In peritoneal dialysis, the peritoneal membrane serves as the semipermeable membrane that uses diffusion and osmosis; ultrafiltration occurs w/ PD by the dialysate fluid having a higher glucose concentration than blood

• Uses a peritoneal catheter placed in the OR

• Slower than HD

List the disadvantages of peritoneal dialysis

1. Protein loss in outflow fluid

2. Risk for peritoneal injury

3. Potential discomfort from indwelling fluid

4. Peritonitis

5. Bowel perforation

List the advantages of peritoneal dialysis

1. Flexible schedules

2. Less dietary and fluid restrictions

3. Better option for patients with severe HTN, HG, pulmonary edema, of older age, who have cardiovascular disease, or diabetes

4. Better for patients who cannot tolerate anticoagulation or who have poor vascular access

List possible complications of peritoneal dialysis

1. Peritonitis

2. Leakage at the catheter site

3. Bleeding

4. Abdominal hernias

5. Hemorrhoids

6. Low back pain

7. Anorexia

What is completed during peritoneal dialysis?

1. Toxins and wastes are removed from the blood by diffusion

2. Ultrafiltration occurs through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration

What is the vascular access for peritoneal dialysis?

Peritoneal catheter

List interventions for the nursing management of a patient with peritoneal dialysis.

1. Meet psychosocial needs

2. Promote home, community-based, and transitional care

3. Protect vascular access

4. Monitor symptoms of uremia

5. Detect cardiac and respiratory complications

6. Control electrolyte levels

7. Manage pain and discomfort

8. Prevent infection

List/describe the types of lower UTIs.

Lower UTIs Include:

1. Bacterial cystitis (inflammation of the urinary bladder)

2. Bacterial prostatitis (inflammation of the prostate gland)

3. Bacterial urethritis (inflammation of the urethra)

About 50% of patients with indwelling catheters become infected within ____ of catheter insertion (cystitis)

1 week

List risk factors for the development of lower UTIs.

1. Female gender

2. DM

3. Pregnancy

4. Neurologic disorders

5. Gout

6. Immunosuppression

7. Instrumentation of urinary tract

8. Obstruction to urinary flow (i.e., kidney stones, ……)

9. Inability/failure to empty bladder completely

What is urethrovesical reflux, what is a complication of it, and what group is it more common in?

• The backward flow (or reflux) of urine from the urethra into the bladder is known as urethrovesical reflux (an obstruction of free-flowing urine)

• It brings bacteria into the bladder from the urethra

• There is an increased incidence of urethrovesical reflux in postmenopausal women

What are the most common bacterial infection in women?

Community acquired UTIs

What are the most common organisms responsible for UTIs? What other organisms commonly cause lower UTIs (cystitis)

• E-coli or other organisms found in the lower GI tract are the most common organisms responsible for UTIs

Other Common Organisms that Cause Lower UTIs:

• Staphylococcus aureus

• Kliebsiella pneumoniae

• Proteus

• Enterobacter

• Fungal: candida

• Trichomonas (rare)

Once an indwelling urinary catheter is placed, how long before bacterial colonization beings?

48 hours

What are the 3 ways that bacteria can enter the urinary tract? Which is the most common?

1. Transurethral route (ascending infection)—>most common route of infection, often from fecal contamination through the urethra or from sexual intercourse (forcing bacteria from the urethra into the bladder in women)

2. Through the bloodstream (hematogenous spread)

3. By an intestinal fistula (direct extension)

What is the most common factor that places clients at risk for UTIs in the hospital setting? Because of this, what is the goal to prevent these UTIs from happening?

Catheters

• Remove the catheter w/in 48 hours after placement whenever clinically possible

List s/s of lower UTIs.

1. Burning on urination

2. Urinary frequency

3. Urinary urgency

4. Nocturia (waking up one or more times during the night to urinate, often resulting in disturbed sleep)

5. Incontinence

6. Suprapubic or pelvic pain

7. Hematuria

8. Back pain

What sx might a patient with a catheter associated UTI have?

Most catheter associated UTIs are asymptomatic

What labs/diagnostic tests are used to evaluate for lower UTIs?

1. Urine tests (i.e., UA, urine culture)

2. CT scan

3. US

4. Kidney scan

List interventions for the management of lower UTIs.

1. Antimicrobial agents

2. Urinary analgesic agents

3. Patient education (hygiene, increase fluid intake, voiding habits, wear cotton underwear)

How are UTIs diagnosed?

• Urine cultures are frequently used to diagnose a UTI; can also identify the specific organism causing the infection = can choose effective antibiotic via C&S testing

• On UA leukocytes, nitrites, bacteria, maybe hematuria

How common are upper UTIs compared to lower UTIs?

Less common than lower UTIs (has to travel further up the urinary tract)

List/describe the types of upper UTIs.

1. Pyelonephritis (inflammation of renal pelvis, tubules, and interstitial tissue)

2. Interstitial nephritis (inflammation of the kidney)

3. Kidney abscesses: A renal abscess is a localized collection of pus (infected fluid) within the kidney tissue (parenchyma) or in the surrounding space (perinephric space) = rare/severe complication of UTIs

What is the goal of tx of UTIs?

=Goal of treatment:  an antibacterial medication that removes bacteria from the urinary tract without damaging the fecal and vaginal flora (minimizing vaginal yeast infections); meds that are affordable with few side effects

List drug classes with example meds used to tx UTIs and pyelonephritis

List patient education on preventing recurrent UTIs

Hygiene

1. Shower rather than bathe

2. Wipe from front to back after each BM

Fluid Intake

1. Hydrate well

2. Maybe 1 glass of cranberry juice daily

3. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.

Voiding Habits

1. Void regularly (every 2-3 hours daily, fully emptying the bladder)

2. Women should void immediately after penile-vaginal intercourse

Interventions

1. Take medication exactly as prescribed

2. Keep in mind that if bacteria continue to appear in the urine, long-term antimicrobial therapy may be required to prevent colonization of the periurethral area and recurrence of infection

3. For recurrent infections, consider taking cranberry juice or capsules daily for longer than 8 weeks

4. If prescribed, test urine for the presence of bacteria following the manufacturer’s and health care provider’s instructions

5. Notify the primary provider if fever occurs or if signs and symptoms persist despite tx

6. Consult the primary provider regularly for follow-up

List age-related changes for men and women that increase risk of UTIs.

Both

1. Neurogenic (dysfunctional) bladder and indwelling catheters increases risk for UTIs

Women

1. Older women can have incomplete emptying of the bladder and/or urinary stasis

2. Postmenopausal women are more at risk of having bacteria in the vagina and urethra (can have recurrent cystitis from lack of estrogen; oral or topical estrogen can be used to restore the acidic pH of the vaginal area)

Men

1. Antibacterial activity of prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging (catheterizations or cystoscopies that are used to diagnose urinary dysfunction, prostatic hyperplasia, or carcinoma increase the number of UTIs in men)

2. Most common cause of recurrent UTIs in older males is chronic bacterial prostatitis (resection of the prostate can help)

For UTIs, what sx are more common in older adults?

1. Incontinence

2. Delirium

3. Burning

4. Urgency

5. Fever

What is pyelonephritis?

A bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

List causes of pyelonephritis.

1. The upward spread of bacteria from the bladder

2. Bacteria spread from systemic sources reaching the kidney via the bloodstream

3. An incompetent ureterovesical valve (= backflow of urine contaminated w/ bacteria)

4. Obstruction occurring in the urinary tract (bladder or prostate tumors, strictures, benign prostatic hyperplasia, and urinary stones)

5. Systemic infections (like tuberculosis)

How is pyelonephritis classified?

Pyelonephritis can be acute or chronic.

What is acute pyelonephritis?

• An acute bacterial infection that leads to enlargement of the kidneys with interstitial infiltrations of inflammatory cells, tubular cell necrosis, and possible abscess formation (abscess = pocket of infection that can occur anywhere in the kidney)

• Can also cause atrophy and destruction of tubules and glomeruli.

List s/s of acute pyelonephritis.

1. Chills

2. Fever

3. Leukocytosis

4. Bacteriuria

5. Pyuria

6. Low back pain

7. Flank pain

8. CVA tenderness

9. N/V

10. HAs

11. Malaise/fatigue

12. Painful urination

13. Tachycardia/tachypnea

14. Burning/urgency/frequency of urination

15. Nocturia

16. Recent cystitis or tx for UTI

What is used in the diagnostic evaluation of a patient for/with acute pyelonephritis?

1. Urine tests: Shows WBCs and bacteria; occasional RBCs & protein may be present; urine should b ecultured to determine causative organism

2. Serologic tests—>blood culture, c-reactive protein, erythrocyte sed rate to determine inflammation and/or cause of recurrent UTIs

3. US

4. CT scan

5. X-rays (KUB)

6. IV pyelogram

7. Radionuclide renal scan (identify active pyelonephritis or abscess in/around the kidney)

List interventions for the management acute pyelonephritis.

1. Antimicrobial agents (2-week course of antibiotics at least, may need for up to 6 wks for relapse)

2. Urinary analgesics

3. Hydration

4. Repeat urine culture 2 weeks after completion of antibiotic therapy

What is chronic pyelonephritis?

A condition caused from repeated episodes of acute pyelonephritis that result in scarred, contracted, and nonfunctioning kidneys

List s/s of chronic pyelonephritis.

1. Fatigue

2. HA

3. Poor appetite

4. Polyuria

5. Excessive thirst

6. Weight loss

7. HTN

8. Inability to conserve sodium = decreased urine concentrating ability (dilute + more urine) = nocturia

9. Tendency to develop hyperkalemia and acidosis

What is used in the diagnostic evaluation of a patient for/with chronic pyelonephritis?

1. Renal function tests—>BUN, creatinine clearance, creatinine levels

2. IV urogram

List complications of chronic pyelonephritis

1. ESKD

2. HTN

3. Kidney stones

List interventions for chronic pyelonephritis.

1. Antimicrobial agents (long-term prophylactic antimicrobial therapy to limit recurrence of infections)—>need to make sure meds are not nephrotoxic

2. Education focused on preventing acute infections

3. If hospitalized, careful monitoring of I&Os

4. 3-4 L of fluids per day to dilute urine, decrease burning on urination, and prevent dehydration (unless contraindicated)

5. Assess vitals q4h; administer antipyretics and antibiotics as prescribed

6. Use NSAIDs appropriately; educate patient on reporting pain

7. Antibiotics to tx infection

8. Urinary antiseptic drugs (Macrodantin—>nitrofurantoin) to provide comfort

What is urinary incontinence?

Unplanned, involuntary, or uncontrolled loss of urine from the bladder

What raises the risk of urinary incontinence in women?

Age, gender, and number of vaginal deliveries are established risk factors for urinary incontinence in women

List risk factors for urinary incontinence

List the types of urinary incontinence.

1. Stress incontinence

2. Urge incontinence

3. Functional incontinence

4. Iatrogenic incontinence

5. Mixed incontinence

6. Overflow incontinence

Describe the pathology of stress incontinence, and explain what group is most often affected by this.

• Most common type of incontinence

• Loss of small amount of urine during coughing, sneezing, jogging, changing positions, jumping, or lifting

• Cannot tighten the urethra enough to overcome the increased bladder pressure caused by contraction of the detrusor muscle

• It predominantly affects women who have had vaginal deliveries. Thought to be the result of decreasing ligament and pelvic floor support or decreased/absent estrogen levels. In men, this can occur after a radical prostatectomy for prostate cancer.

List interventions for stress incontinence

–Journaling, behavioral interventions, diet modification, pelvic floor (Kegel) exercises

–Diet therapy

–Drug therapy: Estrogen

–Surgery

–Vaginal cone therapy

What is urge incontinence? What is it also known as? What might cause urge incontinence?

1. The urge cannot be suppressed. The patient feels the urge but cannot hold it.  (having bladder contractions regardless of the urine volume in the bladder)

2. Also known as overactive bladder

3. May have no known cause or may be the result of abnormal detrusor muscle contractions r/t other problems (from stroke, neurological problems, other urinary tract problems, irritation from concentrated urine-artificial sweetners-caffeine-alcohol-citric intake)

4. Drugs (diuretics) and nicotine can also irritate the bladder

List interventions for urge incontinence

–Drugs: Anticholinergics, antihistamines, others

–Diet therapy: Avoid caffeine and alcohol

–Behavioral interventions: Exercises, bladder training, habit training, electrical stimulation

What is functional incontinence? What factors contribute?

•      Occurs as a result of factors other than abnormal function of the bladder and urethra

•      The lower urinary tract function is intact but other factors, such as cognitive impairment are not (Alzheimers)

List interventions for functional incontinence

–Treatment of reversible causes

–Urinary habit training (if incontinence not reversible)

–Final strategy: Containment of urine, protection of patient’s skin

–Applied devices

–Urinary catheterization

What is iatrogenic incontinence? What resolves this type of incontinence?

•      Involuntary loss of urine due to extrinsic medical factors, usually medications (alpha-adrenergic agents to decrease blood pressure like Doxazosin (Cardura), Prazosin (Minipress), and Terazosin (Hytrin))

•      In people with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure

•      Has same characteristics as stress incontinence

•      If medication discontinued, the incontinence resolves

List interventions for iatrogenic incontinence

–Discontinue the medications that caused it

–Treat the illness causing the need for medications

–Kegel exercises

What is mixed incontinence? What group is this more common in?

• The presence of more than one type of incontinence

• Related to both stress and urge incontinence

• Common in older women

What are common causes of the onset of urinary incontinence?

1. Acute UTI

2. Infection elsewhere in the body

3. Constipation

4. Decreased fluid intake

5. A change in a chronic disease pattern

6. Decreased estrogen levels

List causes of transient incontinence

Atrophic vaginitis, urethritis, prostatitis

•Delirium or confusion

•Excessive urine production (increased intake, diabetes, diabetic ketoacidosis)

•Limited or restricted activity

•Pharmacologic agents (anticholinergic agents, sedatives, alcohol, analgesic agents, diuretics, muscle relaxants, adrenergic agents)

•Psychological factors (depression, regression)

•Stool impaction or constipation

•Urinary tract infections (UTI)

What is used to diagnostically evaluate a patient with urinary incontinence?

1. Urine tests

2. Urodynamic tests

List nonsurgical/nonpharmacologic interventions for urinary incontinence.

Behavioral therapy is the 1st choice for tx urinary incontinence including:

1. Pelvic floor muscle exercises (Kegel exercises 4 times daily)

2. Voiding diary

3. Biofeedback

4. Prompted voiding (timed voiding that is carried out by staff or family members when the patient has cognitive difficulties that make it difficult to remember to void at set intervals)

5. Timed voiding (est set voiding frequency such as q2h if incontinent episodes tend to occur 2 or more hours after voiding = “void by the clock” at a given interval = void regularly every 2 hours)

6. PT

7. Avoid caffeine, alcohol, smoking

8. Bladder retraining (increasing voiding intervals as bladder strengthens)

9. Vaginal cone retention exercises (uses vaginal cones of varying weights)

10. Transvaginal/Transrectal Electrical Stimulation (using electrical stimulation to contract the pelvic floor muscles)

11. Neuromodulation (uses nerve stimulation to inhibit detrusor overactivity and hypersensory bladder signals, also strengthens weak sphincter muscles)

List pharmacologic therapies for urinary incontinence.

1. Anticholinergic agents = 1st-line meds for urinary incontinence (Levsin, Bentyl, HyoMax, Oxybutynin)

2. Alpha adrenergic agents

3. Tricyclic antidepressants can decrease bladder contractions + increase bladder neck resistance (amitriptyline, imipramine)

4. Pseudoephedrine sulfate acts on on alpha-adrenergic receptors, causing urinary retention, can be used to treat stress incontinence; this med needs to be used with caution in men with prostatic hyperplasia and patients with hypertension