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)