Urinary and Lower UTI Incontinence

Urinary Incontinence

• Involuntary leakage of urine

• Functional Incontinence: Affects geriatric patients needing assistance to ambulate to the bathroom.

• Neurogenic Incontinence: Seen with spinal cord injuries, involving lack of bladder control.

• Urgency Incontinence: Occurs in patients taking loop diuretics or those with infections.

• Overflow Incontinence: Caused by bladder not emptying, often due to urethral blockage seen in BPH.

• Risks include geriatric considerations: more frequent bathroom use, decreased bladder capacity, nocturia; and a history of pregnancy with vaginal delivery.

• Teaching should include decreasing coffee intake, stopping smoking, preventing constipation (stress), using the bathroom, and voiding every 2-4 hours (functional).

Lower UTI: Cystitis / Urethritis

• Infection can stem from bacteria, fungus, parasite, chemical irritant, foreign bodies, or trauma.

• Cystitis is a bladder infection often caused by urine stasis.

• Urethritis can result from STIs, immunosuppression, and poor hygiene.

• Proper hygiene involves wiping from front to back to prevent E. coli infections.

• Impaired protective mechanisms can lead to bacterial proliferation during urination.

• Protective mechanisms include the one-way flow of urine, epithelial cells lining the urinary tract, and acidity of the environment.

• Clinical manifestations include frequency, urgency, dysuria, pain, and pink/cloudy urine

• Geriatric patients may experience delirium.

• Pelvic pain is also a symptom.

• Labs: CBC, CMP

• Medications include:

  • trimethoprim/sulfamethoxazole (antibiotic): 2 tabs every 12 hours for 14 days.
  • phenazopyridine (urinary analgesic): 200mg three times a day.

• Drink 8 glasses of water, use sunscreen, and be aware that urine may turn orange.

Acute Pyelonephritis

• Obstruction or ureteral reflux causes contaminated urine to backflow into the kidney, which can be caused by renal calculi.

• Clinical Manifestations: costovertebral angle tenderness, fever, chills, nausea/vomiting, and dehydration.

• Interventions include IV pyelogram, monitoring BUN/Creatinine (contrast), IVF with normal saline (0.9% sodium chloride) for patients at risk for dehydration, and monitoring creatinine for increases greater than 2x the normal amount (0.9 mg/dL).

Chronic Pyelonephritis

• Chronic reflux of contaminated urine causes the kidney to be smaller and inflamed.

• Obstruction from renal calculi causes urinary stasis and bacteria growth.

• Infected urine backflows into the kidneys, resulting in scarring and atrophying.

• Clinical manifestations are vague and inconsistent.

• Interventions include monitoring BUN/Creatinine, urinary analgesics, antipyretics, and antibiotics.

• Input and output should be similar, with a minimum of 1500ml a day, and intake should be 3-4L daily.

Renal Calculi (nephrolithiasis / urolithiasis)

• Increased concentration of particles in urine causes stone formation, leading to obstructions.

• Clinical manifestations include renal colic, dull and localized flank pain, nausea/vomiting, and hematuria.

• Interventions include opioid medication for pain and drinking 2 glasses of water at bedtime.

• Preventative teaching: avoiding activities with excessive sweating (dehydration), decreasing protein intake, and avoiding oxalate-containing food like spinach, strawberries, and wheat bran.

Acute Glomerulonephritis

• An infection elsewhere in the body causes the immune system to attack glomeruli walls, making them permeable and increasing GFR.

• Symptoms include coffee-colored urine, headache, hypertension, periorbital edema, edema, and SOB.

• Interventions include VS Q4H, CBC and CMP daily, fluid restriction to prevent overload, and consuming carbs for energy while reducing protein breakdown.

Chronic Glomerulonephritis

• The kidneys become hard and small due to chronic proteinuria and hypertension, leading to renal damage, scarring, atrophy, and CKD.
• Manifestations: weight loss, decreased strength, nocturia, hyperkalemia, metabolic acidosis, headache, anemia, pericardial rub.
• Treatments: high-protein diet, diuretics and antihypertensives, dialysis, and strict I/O.

Nephrotic Syndrome

• Increased glomerular permeability leads to massive proteinuria, damaging the glomerular membrane; and the disease may be caused by lupus, infection, cancer, vasculitis, or DM.

• Edema is noted due to albumin loss, decreasing oncotic pressure and causing fluid to escape.

• Hepatocytes increase lipid synthesis, leading to hyperlipidemia, along with hypoalbuminemia.

• This increases the risk for thrombus and generalized edema.

• Monitor skin integrity (sacral area) for breakdown, monitor for thrombus/PE, UA- Protein, and WBC.

• Administer ACE inhibitors, diuretics, and lipid-lowering medications.

Polycystic Kidney Disease

• Genetic disease (recessive or dominant) that can spread to structures/organs.

• Dominant form spreads to other structures and organs.

• A liver biopsy can determine if the form is recessive vs dominant.

• Recessive form: respiratory distress, enlarged kidneys, systemic HTN

• Dominant form: 40-50 y/o, decreased urine concentration, HTN, proteinuria, hematuria, pain

• Supportive care, apply heat to the abdomen for comfort, prevent dehydration with fluids, avoid NSAIDs.

Acute Kidney Injury

• Acute loss of renal function due to perfusion issues (MI, DM, HTN, CA, BPH, Nephrotoxic drugs)

• Pre-renal (peripheral vascular disease): decreased blood flow to the kidney

• Intra-renal: nephrons constricted/blocked, disrupting flow inside

• Post-renal: obstruction

• Example: Cardiac Infarction leads to pre-renal injury due to decreased kidney perfusion.

• The RAAS system tries to compensate with fluid and dilation. If uncorrected, pre-renal injury can progress to Intra-renal injury.

• Clinical Manifestations: electrolyte and ABG imbalance

• Oliguric phase (no urine) & Diuretic phase (hypovolemia/ urine is not concentrated)

• Recovery phase (electrolytes normalize, like potassium)

• Acute Tubular Necrosis: damage to tubules, vasoconstriction (seen in intra-renal injuries)

• Risks: Hemorrhage (decreased volume = less kidney perfusion = injury)

• Limit NSAIDs, contrast, and nephrotoxic meds

• Strict I/O

• Diet: High-carb and no potassium or phosphorus.

Chronic Kidney Disease

• Damage to nephrons causing them to not work; other nephrons compensate but ultimately fail.

• Is often seen in patients with uncontrolled HTN, DM, smoking, and long-term impaired circulation

• Will typically require dialysis.

• Patients are at risk for anemia from decreased erythropoietin production (which comes from the kidney sent to the bone marrow to produce RBCs).

• End Stage Renal Disease (CKD in Stage 5): patients are at risk for bone disorders (bone breakdowns/fractures) because of vitamin D deficiency, increased phosphorus and decreased calcium.

• Clinical Manifestations: edema, pulmonary congestion, pericardial friction rub

• Types of Dialysis:

  • Hemodialysis, Peritoneal Dialysis, Continuous Renal Replacement Therapy (CRRT)

• Monitor for 2lbs weight gain in one nursing shift (fluid restriction), notify provider of decreased/minimal UOP.

• Hold BP and cardiac meds for dialysis as they will be removed from the system, do not give Ketorolac, avoid potassium/phosphorus, provide high carb diet, calcium binders, and antihypertensives

Kidney LABS:

• BUN (Increased): 10-20mg/dL
• Serum Creatinine (Increased): 0.6-1.2 mg/dL
• GFR (decreased): 90-120 ml/min.
• Hbg (Low / Anemia): Male 14-18 g/dL, Female 12-16 g/dL
• RBC (Low): Male 4.7-6.1, Female 4.2-5.4
• Triglycerides (high): Male 40-60mg / dL, female 35-135 mg/dL
• Potassium (increased): 3.5-5 mEq/L
• ABG / Ph: Acidosis (pH <7.35)
• Calcium (low): 9-10.5
• Phos (increased): 2- 4.5 mEq/L

Geriatric Considerations GU Issues:

• Medications may not be metabolized properly due to decreased filtration.
• Pelvic muscle exercises (Kegel) and set time for bathroom breaks.

Stomatitis

• Idiopathic ulcerations of the oral mucosa, commonly with chemo patients; radiation therapy/autoimmune disorders; or bacteria/virus (HSV).
• Clinical Manifestations: pain, ulcers
• Monitor concerns with swallowing/chewing, may use NGT or PICC for TPN or Magic Mouthwash.

GERD

• Lower esophageal sphincter not closing efficiently causing regurgitation of gastric acid/food, restrictive clothing and weight gain, smoking, pregnancy, caffeine, alcohol, or fatty food.
• Clinical Manifestations: heartburn, chest pain, dysphagia, Barrett's esophagus
• Tx / Dx: Omeprazole (PPI), ranitidine (H2 Blocker), stop smoking/drinking, low-fat diet, no milk, peppermint, soda, and weight loss.

Hiatal Hernia

• Idiopathic- loosening of the muscular band around the esophagus and diaphragmatic junction causing part of the fundus to be above the diaphragm.
• Dysphagia, GERD, life-threatening if incarcerated (strangulation), or belching/regurgitation
• Barium swallow study, EGD and surgery
• Diet restrictions.

Esophageal Varices

• Enlarged veins of the esophagus are caused by portal hypertension
• Clinical Manifestations: variceal bleeding- Hematemesis (Vomiting blood), melena (dark tarry stool), anemia, and hemorrhage which equals shock
• Tx / Dx: IV Octreotide (antidiarrheal/ splanchnic vasoconstriction)

Gastritis

• Inflammation of the stomach lining (from aspirin, alcohol, irritation and H. Pylori)
• Clinical Manifestations: asymptomatic, nausea/vomiting, or postprandial discomfort after meals
• Tx / Dx: Avoid NSAIDs/ ASA for pain. Education: physical activity to reduce stress, avoid alcohol and caffeine, and notify PCP if stool is dark

Gastroenteritis

• Acute inflammation of the stomach and small intestine
• Diarrhea, pain, nausea/vomiting, fever, malaise and abdominal discomfort
• Tx / Dx: Treat like a stomach bug with IVF and bowel rest

Peptic Ulcer Disease

• Stomach acid in the Upper GI damages the lining of the digestive tract, breakdown of epithelial mucosal barrier, duodenal or gastric area.
• Pain, burning, nausea, and dyspepsia during the day when the stomach is empty, Hemateemesis is concerning (GI Bleeding)
• Notify the PCP if there is coffee ground -seen with emesis or NGT drainage, EGD Procedure, and surgery

Ulcerative Colitis

• Inflammatory Bowel Disease that only affects the colon, it starts at the base of the crypts of Lieberkühn, leading to abscess formation in the epithelia of the crypts, which causes exudative diarrhea.
• Serious complication: Toxic Megacolon (Swelling inflammation of the colon), where the colon stops and may rupture.
• Clinical Manifestations: Abdominal pain, bloody diarrhea, and rectal bleeding.
• Tx / Dx: LOW FIBER, high protein, high-calorie diet, Corticosteroids, immunomodulators, Labs CBC (for bleeding), Stool Albumin.

Crohn’s Disease

• Inflammatory Bowel Disease that affects the entire Gl tract, a cobblestone-like appearance can be throughout the entire GI tract.
• Clinical Manifestations: malnutrition ,toxic megacolon, diarrhea (bloody), abdomen pain, skin conditions, arthritis, fever,
• Tx / Dx: Corticosteroids, antibiotics TPN, Elevated WBC normal (5-10), Elevated ESR, or abnormal electrolytes.

Enterocolitis (Antibiotic Associated Colitis /Pseudomembranous colitis)

• Also known as C. Diff, the large intestine is exposed to bacterial toxins, causing inflammation, and mucosal necrosis,
• Clinical Manifestations: Elevated WBCs, fever, abdomen pain, sepsis, and profuse watery foul-smelling diarrhea,
• Tx / Dx: Precaution Antibiotics.

Appendicitis

• Inflammation of the vermiform appendix caused by a hard strong mass of feces
• Symptoms: fever, diarrhea, nausea, and migrating pain at McBurney's point (RLQ)
• Interventions include: maintaining hydration, educating to go to ER, treat fever with antipyretic, appendectomy surgical care, and administer no laxatives, antibiotics, IVF, opioids, and antipyretics

Diverticulosis / Diverticulitis

• Diverticulosis creates polyps in the intestinal tract, it is related to low fiber intake and high-pressure
• Clinical Manifestations: LLQ Pain, Elevated WBC, Constipation/ diarrhea, complications sepsis, Obstruction and perforation
• Tx /Dx: Antibiotics, laxatives/ fiber, drink eight glasses of water increase soft cooked Veggies/ No corn/nuts.

Irritable Bowel Syndrome

• Non-inflammatory condition with idiopathic Constipation N diarrehea- abdominal pain improved and resolved by defication
• Tx/ Dx: Medication (Dicyclomine) (Food med will taste different)

Intestinal Obstruction

• Impacted faces or blockage which can be either large/ small
• Mechanical/ Obstruction- from scar tissues N tumor N inflammation.
• Functional- loss of propulsive ability aka lleus (occurs after surgery
• Tx /Dx: NPO Bowel rest, IVF-for fluid to breakup hard stools. NG tube 4 low intermittent Suction If patient has Fever N Tachcardia

Celiac Disease

• With genetically pre-disposed persons, the intestinal Villi atrops leading towards Malabsorbtion which affects more females then males.
• Clinical Manifestations: Weight Loss/Malnutrition. Diarreah/ joint pain, and tooth enamil loss
• Tx/Dx: Foods that avoid triggering gluten

Dumping Syndrome

• Impaired rapid gastric emptying ( Malabsorbtion)
• 39 min from nutrients that are eaten.