3 Ps 2- EXAM 4

There are multiple forms of urinary incontinence (UI), including

Urge incontinence

Stress incontinence

Mixed incontinence

Overflow incontinence

Functional incontinence

Urge incontinence

sudden strong urge to void and frequently does not have sufficient time to respond to the urge before urine leaks from the bladder.

It is often the result of an overactive detrusor muscle.

Risk factors- age, infection, and obstruction of the bladder outlet by an enlarged prostate gland.

also common in clients with degenerative nerve diseases such as Parkinson disease, multiple sclerosis, or a history of stroke, due to CNS damage.

Stress incontinence

caused by a sudden increase in intra-abdominal pressure as with sneezing, coughing, and bending, causing the urine to leak from the bladder.

may be due to loss of pelvic muscle support of the bladder and urethra.

Risk factors- estrogen depletion, obesity, childbirth trauma, and cancer therapies.

also evidence that damage to the spinal nerves due to diabetes may also contribute to the loss of support.

Mixed incontinence

combined symptoms of urge and stress incontinence.

prevalent in older female clients.

Overflow incontinence

results from obstruction of the urethra, which limits the amount of urine that is emptied with each void.

This increases the residual volume of urine, which can lead to stasis of the urine and infection. This condition is most common in older adult male clients with benign prostatic hypertrophy.

Functional incontinence

results from a factor other than urinary system alterations.

often presents with other deficits such as immobility.

The client has an intact urinary system but cannot respond quickly enough to avoid incontinence

Impaired urinary elimination types

•Anuria

•Dysuria

•Oliguria

•Urinary Frequency

•Urinary urgency

anuria

marked by the absence of urine output

frequently encountered in cases of kidney failure

presents as less than 50 mL of urine within a 24 hr period

oliguria

Reduced urine output

may indicate potential issues such as dehydration, fluid retention, or diminishing kidney function

urinary frequency

urge to urinate multiple times throughout the day or night (nocturia

often accompanied by a compelling sense of urgency, introducing another layer of concern

urinary urgency

sensation of an urgent need to void

may lead to urge incontinence if prompt access to a restroom is not possible.

polyuria

Excessive urine output

surpassing 2.5 L over twenty-four hours

potential indicator of various medical conditions.

Assessing Bladder
Beginning with

light palpation, the nurse will assess the lower abdomen

when is the bladder not palpable

empty

Using deeper palpation, the nurse should attempt to

feel the base of the bladder

If the bladder is palpable, the nurse should

continue to palpate, outlining the bladder.

A bladder that is mildly full will be

slightly firm and nontender, below the umbilicus

A bladder that is full may be

firm and may extend above the umbilicus.

Palpation

Suprapubic area note

bladder distention

Palpation

Costovertebral angle (CVA) tenderness

pain indicate kidney involvement

on back

are the kidneys palpable in adults

not normally

Assessing Urine

color

pale yellow, dark, amber, red, cloudy

Assessing Urine

clarity

clear vs. cloudy

Assessing Urine

odor

strong, foul, sweet

Assessing Urine

amount

•Normal adult output: ≥30 mL/hr

Assessing Urine

presence of

sediment, mucus, or blood

Intake & Output (I&O)

Measure urine output

Compare intake vs output

Watch for oliguria or anuria

Assess trends over time (especially post-op or CHF patients)

Genitourinary Drugs

•Anticholinergics – oxybutynin chloride (Ditropan)

•Cholinergics – bethanechol (Urecholine)

Anticholinergics used to treat

urinary incont. and overactive bladder

Cholinergic to treat

urinary retention

oxybutynin (Ditropan)
Anticholinergic

action

Oxybutynin is an anticholinergic (specifically, an M3 muscarinic receptor blocker).

In the bladder, acetylcholine normally binds to M3 receptors and causes the detrusor muscle to contract (→ makes you feel like you need to urinate).

Oxybutynin blocks those M3 receptors, which leads to

Decreased detrusor muscle contractions

Increased bladder capacity

Less urgency & frequency

Less urge incontinence

oxybutynin (Ditropan)
Anticholinergic

ADR

Everything dries up

Dilation of pupils- mydriasis

CNS drowsiness or confusion

adr image

Monitor

anticholinergic effects for ADR

I&O

Distended bladder

have eye exams can increase interocular pressure

don’t give if

GU or GI obstruction

bethanechol (Urecholine)
Cholinergic

action

•Stimulates acetylcholine, which causes bladder contraction

bethanechol (Urecholine)
Cholinergic

indication

acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention

bethanechol (Urecholine)
Cholinergic

ADR

increased salivation, gastric acid excretions, dilation of blood vessels hypotension and fainting, bronchospasms

Safety alert- monitor

VS

respiratory status

watch for postural hypotension

Report SOB or bronchospasm

Diarrhea

nurse consider

Warm them they will urinate a lot, increase the fluid intake to compensate.

Can’t give with a cholinesterase inhibitor (we learned about in neuro) because it will double amount of acetylcholine

cholinergic toxidrome mnemonic SLUDGE

Salivation

Lacrimation

Urination

Diaphoresis

G I distress

Emesis

Urinary Analgesic

Phenazopyridine Hydrochloride

used to

relieve pain and discomfort associated with the urinary tract

Urinary Analgesic

Phenazopyridine Hydrochloride

tx conditions ex

UTIs and interstitial cystitis (also known as bladder pain syndrome)

Urinary Analgesic

Phenazopyridine Hydrochloride

action

numbing or reducing the sensitivity of the urinary tract, thus alleviating pain during urination.

Urinary Analgesic

Phenazopyridine Hydrochloride

relief of

Symptomatic relief of pain and burning arising from irritation of the lower urinary tract mucosa

Relief of urinary frequency and urgency and of pain and burning of the urinary tract mucosa

Urinary Analgesic

Phenazopyridine Hydrochloride

urine color

may turn the urine, saliva, or tears a reddish-orange color. This is an expected effect of the medication and does not harm the client.

Before administering the drug, assess the client’s renal and liver function because

drugs may cause renal or hepatic toxicity in clients who have insufficiency in these areas

The client taking a urinary analgesic should not:

Take extra doses- may cause serious adverse effects such as hemolytic anemia or renal or hepatic toxicity.

Wear contact lenses while taking phenazopyridine hydrochloride because it may stain them a reddish-orange.

Drink alcohol while taking urinary analgesics because their interaction may cause serious effects such as confusion, disorientation, and cardiac arrhythmias.

Take this medication longer than 2 days because doing so could mask symptoms of a bacterial infection that is not resolving.

major functions of the kidney include

blood pressure control

erythropoietin production for red blood cell regulation

filtration of waste products and excretion as urine

regulation of acid-base balance

regulation of electrolytes

regulation of water/fluid balance

synthesis of vitamin D to its active form

Two of the most common disorders that affect the kidneys are

acute tubular necrosis (ATN)

chronic kidney disease (CKD)

One of the biggest risk factors for kidney disease is

diabetes mellitus because this condition often results in nephropathy, or problems with the kidney vasculature

Patient Populations at Risk for Kidney Disease

•African, American Indian, or Asian heritage

•diabetes mellitus

•family history of kidney disease

•glomerulonephritis

•hypertension

•increasing age

•medication use (e.g., nonsteroidal anti-inflammatory drugs, antibiotics)

•obesity

•polycystic kidney disease

•pyelonephritis

•smoking

•urinary tract obstruction (e.g., urinary tumors, enlarged prostate, kidney stones)

Common Conditions Affecting Kidney Function

Congenital Abnormalities

Genetic Disorders

Neoplasms (Kidney Tumors)

Infection (Pyelonephritis)

Glomerular Disorders (Glomerulopathies)

Renal Calculi (Kidney Stones)

Congenital Abnormalities

Renal agenesis:

No kidneys develop → not compatible with life.

Congenital Abnormalities

Renal hypoplasia

Only one kidney develops → survival possible, but often occurs with other congenital issues

Genetic Disorders

Polycystic Kidney Disease (PKD):

Fluid-filled cysts form in kidneys → interfere with urine formation, cause pain, infection risk, hypertension, and progressive kidney failure.

Neoplasms (Kidney Tumors)

Risk factors:

Smoking, obesity, hypertension, dialysis history, toxins.

Neoplasms (Kidney Tumors)

Wilms Tumor (Children): Presents with

kidney enlargement & hypertension; has high survival rate with treatment.

Infection (Pyelonephritis)

Kidney infection usually caused by

risk increases with

can progress to

E. coli traveling up from bladder.

Risk increases with indwelling catheters.

Can progress to chronic kidney damage if untreated

Glomerular Disorders (Glomerulopathies)

Cause

proteinuria, decreased GFR, edema, and hypertension.

Glomerular Disorders (Glomerulopathies)

Often progress to

end-stage renal disease (ESRD)

Glomerular Disorders (Glomerulopathies)

Nephrotic Syndrome:

Massive protein loss, edema, hypertension → commonly leads to ESRD

Renal Calculi (Kidney Stones)

Usually calcium-based.

Risk factors:

Hypertension, high protein/sodium intake, immobility, family history, hyperparathyroidism

Renal Calculi (Kidney Stones)

Usually calcium-based.

can cause

severe flank pain (renal colic) if obstructing the ureter.

Renal Calculi (Kidney Stones)

Usually calcium-based.

Prevention

Increase fluid intake (2–3 L/day), limit sodium and protein, avoid excess calcium supplements

acute kidney injury (AKI)

sudden reduction in kidney function

caused by

insult to the nephron unit that manifests with alteration in laboratory values and decreased urine output.

many etiologies for the development of AKI

three types of acute kidney injury (AKI)

pre-renal

intra-renal

post-renal

Memory Hook

Pre = pressure problem

Intra = injury problem

Post = plumbing problem

pre-renal

problem and key finding

decrease blood flow

dehydration, shock

intra-renal

problem and key finding

kidney damage

nephrotoxins, ATN

post-renal

problem and key finding

obstruction

BPH, stones

Prerenal causes

Conditions that result in decreased perfusion to the kidneys

Burn injury

Hemorrhage

Hypovolemic shock

Prolonged vomiting or diarrhea

Intrarenal causes

Conditions that result in direct damage to kidney tissue itself

Nephrotoxic medications (e.g., aminoglycosides, contrast media)

Prolonged ischemia from prerenal causes

Postrenal causes

Conditions that block the outflow of urine

Benign prostatic hyperplasia

Blood clots

Renal stones or tumors

Chronic kidney disease (CKD)

progressive and irreversible loss of kidney function that occurs over months to years

Damage to the nephrons leads to

decreased glomerular filtration rate (GFR)

which reduces the kidneys’ ability to

remove waste products, regulate electrolytes, maintain acid–base balance, and control fluid volume and blood pressure

As functioning nephrons are lost, the remaining nephrons attempt to

compensate by hyperfiltration, which temporarily maintains GFR but further accelerates nephron damage

damage includes

Reduced erythropoietin production leads to anemia, and impaired vitamin D activation results in calcium–phosphorus imbalance and bone demineralization (renal osteodystrophy)

The following events leading to scarring and fibrosis are complex, overlapping, and multistage phenomena

•Infiltration of damaged kidneys with extrinsic inflammatory cells.

•Activation, proliferation, and loss of intrinsic renal cells (through apoptosis, necrosis, mesangiolysis, and podocytopenia).

•Activation and proliferation of extracellular matrix producing cells, including myofibroblasts and fibroblasts.

•Deposition of extracellular matrix, replacing the normal architecture.

Daily Weights

•Most sensitive indicator of fluid balance

•More reliable than I&O alone

1 kg (2.2 lb) ≈

•1 liter of fluid

Skin & Mucous Membranes findings

•Edema

•Uremic frost (rare, severe)

•Pruritus (itching)

•Pallor (↓ erythropoietin → anemia)

•Dry skin, poor turgor

Neurological Status

Often overlooked but very important.

Assess for:

•Confusion

•Lethargy

•Difficulty concentrating

•Asterixis (advanced)

kidney meds

•Diuretics (fluid & BP control)

•ACE Inhibitors & ARBs (renal protection vs risk)

1.Diuretics (fluid & BP control)

Manage fluid overload

Common in CHF + renal overlap

Can cause or worsen pre-renal AKI if overused

2. ACE Inhibitors & ARBs (renal protection vs risk)

Protect kidneys in diabetes & HTN

Can increase creatinine initially

Risk for hyperkalemia

•Diuretics (fluid overload)

Furosemide- Used in CKD with fluid overload

•Ace Inhibitors/ARBs (renal protective)

Lisinopril/Losartan- Protect kidneys in diabetes and hypertension

Decrease intraglomerular pressure

Can increase potassium

•Epoetin alfa

tx anemia

Epoetin

Stimulates RBC production

Used when kidneys fail to produce erythropoientin

Electrolyte Management for Hyperkalemia

Sodium bicarbonate

Calcium gluconate

Insulin + dextrose

Sodium polystyrene

Why they matter

Kidneys regulate electrolytes & pH

Hyperkalemia = life-threatening

Electrolyte Management for Hyperphosphatemia

Phosphate Binders - CKD focus

Calcium carbonate

Why they matter

Prevent hyperphosphatemia

Reduce bone disease risk

Teaching Point— Take with meals

Medication Risk Assessment

•Instead of just “what meds are they on,” assess:

•Nephrotoxic meds:

•NSAIDs

•ACE inhibitors / ARBs (context matters)

•Aminoglycosides

•IV contrast

•Recent medication changes

•Dose adjustments needed for renal function

endocrine glands

pituitary, thyroid, parathyroid, adrenal and pineal

Primary function:

secrete hormones directly into surrounding fluid