Alterations in Elimination Flashcards

Alterations in Elimination: Bladder & Bowel Pathophysiology

Conditions of Urinary Elimination

  • The urinary system consists of the kidneys, ureters, bladder, and urethra.

Urolithiasis - "Kidney Stones"

  • Urolithiasis is the presence of stones (calculi) in the urinary tract.
  • It is a common condition.
  • Stones can occur in the kidneys, ureters, bladder, and urethra.
  • Occurs when minerals and salts in the urine crystallize (uric acid, calcium, oxalate, struvite).
  • Calcium oxalate is the most common type of stone.
  • Causes mild to severe pain.
  • Can cause damage to the urinary tract and infections.

Nephrolithiasis

  • Nephrolithiasis, renal calculi, and urinary calculi all refer to the presence of stones (urolithiasis).
  • Five types of stones:
    • Calcium oxalate
    • Calcium phosphate
    • Struvite
    • Uric acid
    • Cystine

How Kidney Stones Affect the Body

  • Symptoms include:
    • Nausea and vomiting
    • Severe pain in the back, abdomen, or groin
    • Blood in the urine
    • Strong need to urinate
    • Frequent urination
    • Urinating small amounts
    • Burning sensation while urinating
    • Urine that smells bad
    • Possible fever and chills
    • Gravel in the urine
    • Pain at the penis tip

Kidney Stone (Urolithiasis) Treatments

  • Medications:
    • \alpha-blockers (alpha blockers): help the stone pass naturally by relaxing the ureters
    • Calcium channel blockers
    • Thiazide diuretics
    • Corticosteroids
  • Invasive and non-invasive procedures:
    • Lithotripsy: breaks up stones into smaller pieces via ultrasound "shock" waves
    • Percutaneous Nephrolithotomy: small surgical incision made to access the kidney to remove large stone(s)

Lithotripsy

  • Uses ultrasound shock waves to break up kidney stones into smaller pieces that can then easily pass through the ureters.

Nursing Interventions

  • Encourage increased oral intake to 3,000 mL/day unless contraindicated.
  • Administer IV fluids as prescribed.
  • Encourage ambulation.
  • Provide client education regarding the role of diet and medications in the treatment and prevention of urinary stones.
  • Calcium phosphate dietary interventions:
    • Limit intake of food high in animal protein (reduction of protein intake decreases calcium precipitation).
    • Limit sodium intake.
    • Reduced calcium intake (dairy products) is individualized.
  • Medications:
    • Thiazide diuretics (hydrochlorothiazide) to increase calcium reabsorption.
    • Orthophosphates to decrease urine saturation of calcium oxalate.
    • Sodium cellulose phosphate to reduce intestinal absorption of calcium.

Urinary Incontinence

Urinary Incontinence Explained

  • Urinary incontinence is the involuntary leakage of urine.
  • Causes:
    • Weakened pelvic floor muscles
    • Nerve damage
    • Pregnancy and childbirth
    • BPH (Benign Prostatic Hyperplasia)
    • Neurologic disorders
    • Spinal nerve injuries
    • Medications
    • Impaired cognitive function

Types of Urinary Incontinence

  • Stress Incontinence: due to increased abdominal pressure under stress (weak pelvic floor muscles).
  • Urge Incontinence: due to involuntary contraction of the bladder muscles.
  • Overflow Incontinence: due to blockage of the urethra.
  • Neurogenic Incontinence: due to disturbed function of the nervous system.

Common Symptoms of Urinary Incontinence

  • Leakage during activities such as coughing, sneezing, or exercising (Stress Incontinence).
  • Sudden urges: An intense need to urinate that can lead to leakage (Urgency Incontinence).
  • Overflow: Frequent dribbling due to incomplete bladder emptying (Overflow Incontinence).
  • Mixed symptoms: A combination of stress and urgency incontinence.

Treatments for Urinary Incontinence

  • Medications: \beta-agonist, anticholinergics, \alpha-blockers, estrogen therapy, Botox injections ("Bladder Botox"), antidepressants.
  • Increase fluid intake.
  • Kegel Exercises.
  • Surgery.

Nursing Interventions for Urinary Incontinence

  • Restoring Bladder control: Bladder training, Kegel’s, timed voiding, urge suppression techniques.
  • Symptom management: Lifestyle modifications (diet), fluid management, medications, assistive devices, environmental modifications.
  • Preventing complications: Skin care, hygiene, patient education.
  • Multidisciplinary collaboration.

Polycystic Kidney Disease (PCKD)

Polycystic Kidneys

  • Genetic disorder.
  • Growth of multiple cysts in the kidneys.
  • Cysts can grow large and impair kidney function.
  • Can lead to kidney failure.

Stages of Polycystic Kidney Disease

  • Based on eGFR (estimated Glomerular Filtration Rate) in mL/min/1.73 m\textsuperscript{2}:
    • Stage 1: eGFR \ge 90
    • Stage 2: eGFR 60-89
    • Stage 3: eGFR 30-59
    • Stage 4: eGFR 15-29
    • Stage 5: eGFR < 15

Common Comorbidities of Polycystic Kidney Disease

  • Hypertension
  • Urinary Tract Problems
    • Infections
    • Kidney stones
  • Reproductive Problems
    • Higher risk of preeclampsia during pregnancy
  • Digestive System Problems
    • Liver cysts
    • Pancreatic cysts
    • Diverticula
  • Vascular Problems
    • Abnormal heart valves
    • Brain aneurysms

Two Types of PCKD

  • Autosomal Dominant Polycystic Kidney Disease (ADPKD):
    • Inherited with only one gene mutation that can cause this disease - PKD1 or 2 (one parent).
    • Cysts occur in Kidneys and liver.
    • Symptoms: Pain in back or side, hematuria, HTN.
    • Occurs primarily in adulthood (~age 30-50).
    • Can lead to kidney failure.
    • More severe and more common.
  • ARPKD (Autosomal Recessive Polycystic Kidney Dz.)
    • Inherited gene mutation - PKHD1 (both parents).
    • Development of cysts in the kidneys and liver.
    • Symptoms: Enlarged kidneys, HTN, breathing problems, liver problems.
    • Occurs before birth and infancy.
    • End stage renal failure (ESRF).
    • More severe and rare.

Autosomal Dominant vs Recessive PKD

  • Autosomal Dominant PKD (ADPKD):
    • More common and less severe form (prevalence: 1 in 500-2,000).
    • Typically adult onset ("adult PKD").
    • Hypertension in most adult patients.
    • ICA (intracranial aneurysm) in ~10% of patients.
    • ESRD (end-stage renal disease) in 50% of patients by 60 years.
    • Mutations in PKD1 (80%), PKD2 (15%) and other genes (rare).
  • Autosomal Recessive PKD (ARPKD):
    • Rare and more severe form (prevalence: 1 in 20,000-30,000).
    • Typically pediatric onset ("juvenile PKD").
    • 30-50% neonatal mortality (due to pulmonary hypoplasia).
    • Hypertension in 75% of children.
    • ESRD in 60% of patients by 20 years.
    • Mutations in PKHD1 (>90%) and other genes.

Conditions Associated with PCKD

  • Urinary tract infections
  • Infected or bleeding cysts
  • Kidney Pain
  • Abdominal discomfort and bloating
  • Kidney stones
  • High blood pressure
  • Reduced kidney function

Management of PCKD

  • Follow a low sodium, low potassium diet
  • Pain management
  • Controlled blood pressure
  • Include daily physical activity
  • Treating urinary tract infections immediately

Treatments and Interventions for PCKD

  • Medications:
    • Vasopressin receptor antagonist: slow progression of disease by targeting cyst growth (Tolvaptan).
    • Antihypertensives: ACE inhibitors, ARB’s
  • Pain management
  • Infection prevention
  • Lifestyle modifications (controlling salt intake, exercise etc…)

Bowel Disease and Incontinence

Diverticulitis

Diverticulosis vs Diverticulitis

  • Diverticulosis: pouches that develop in the lining of the colon wall.
  • Diverticulitis: a condition where small pouches in the lining become inflamed and sometimes infected.
  • These conditions occur mostly in older adults.

Diverticulitis Explained

  • Diverticulitis is the inflammation or infection of small pouches in the colon (diverticula), ranging from mild to severe.
  • Causes & Risk Factors: Low-fiber diet, inactivity, aging, and increased colon pressure.
  • Symptoms: Pain, fever, nausea, vomiting, bowel changes, bleeding, abscesses (severe cases).
  • Diagnosis: Confirmed through clinical evaluation and CT scan.
  • Treatment:
    • Mild cases: rest, liquid diet, antibiotics.
    • Severe cases: surgery. A high-fiber diet helps prevent recurrence.

How Diverticulitis Affects the Body

  • Symptoms include:
    • Abdominal Pain
    • Fever
    • Nausea
    • Vomiting
    • Constipation
    • Chills
    • Night Sweats

Treatments and Management of Diverticulitis

  • Antibiotics
  • Bowel rest
  • Surgery
  • Pain relief
  • Clear liquid diet (hospital)
  • Diet: high fiber, avoid foods with seeds, spicy, greasy foods, red meats, FODMAP foods, foods difficult to digest.
  • Hydration
  • Exercise
  • Weight management (healthy weight)

Recommended Diet During a Diverticulitis Flare-Up

  • Broth
  • Fruit juices without pulp
  • Gelatin
  • Ice chips
  • Ice pops without bits of fruit or fruit pulp
  • Tea or coffee without cream

Fecal Incontinence

Normal Bowel and Bladder Habits

  • By age 5, approx. 4-6 urinations per day.
  • By age 4, approx. 4-9 bowel movements per week.
  • 15% of girls and 22% of boys experience constipation.
  • 12% of children have constipation and 30-50% of children with lower urinary tract complications are affected by bedwetting.

Functional Fecal Incontinence (FFI)

  • Involuntary or inappropriate passage of stool in children and adults.
  • Stool can build up in the rectum and cause overflow incontinence.
  • Children:
    • Usually caused by withholding stool
    • Cognitive and developmental delays
    • Behavioral (Autism, ADHD)
    • Exhibit signs of constipation (infrequent BM’s, straining, hard stool)
  • Adults:
    • Can range from occasional leakage to frequent soiling
    • Can be caused by pelvic floor dysfunction, nerve damage, chronic digestive issues

Functional Fecal Incontinence: The Cycle

  • Painful defecation leads to voluntary withholding.
  • Changes in routine (diet, stressful events, postponing defecation) can contribute.
  • Too early toilet training can also be a factor.
  • Prolonged fecal stasis:
    • Re-absorption of fluids
    • Increase in size & consistency

Chronic Constipation and Fecal Impaction

  • Normal stool in rectum leads to normal bowel function.
  • Chronic constipation can lead to large stools getting stuck in the colon, causing more stool to back up.
  • Fecal impaction with overflow diarrhea:
    • Hard stool can become impacted in rectum.
    • Liquid stool then spills around the edges and can lead to soiling, often without sensation.

Fecal Impaction

  • HARD MASS of COMPACTED STOOL
  • Not VOLUNTARILY EVACUATED
  • From CHRONIC CONSTIPATION
  • Associated with: decreased ABILITY to SENSE & RESPOND to MM BURDEN of STOOL

Complications

  • BOWEL ULCERATION
  • PERFORATION

Bristol Stool Chart

  • Type 1: Separate hard lumps, like nuts.
  • Type 2: Sausage-shaped but lumpy.
  • Type 3: Like a sausage but with cracks on its surface.
  • Type 4: Like a sausage or snake, smooth and soft.
  • Type 5: Soft blobs with clear-cut edges (easily passed).
  • Type 6: Fluffy pieces with ragged edges, a mushy stool.
  • Type 7: Watery, no solid pieces. Entirely liquid.

FFI Treatments and Interventions

  • Preventive measures
  • Lifestyle changes (diet, exercise, physical therapy)
  • Medications: antidiarrheals (loperamide) and laxatives (psyllium). May be used in combination.
  • Enemas
  • Bowel training
  • Pelvic floor strengthening exercises (Kegel’s)
  • Biofeedback
  • Sacral nerve stimulators
  • Bulking Agent injections
  • Anal plug
  • Surgical treatments (Sphincteroplasty)