Urinary Incontinence & Lower UTI

Urinary Incontinence

• Functional incontinence occurs in geriatric patients needing help ambulating to the bathroom.
• Neurogenic incontinence is due to spinal cord injuries causing lack of bladder control.
• Urgency incontinence is seen in patients taking loop diuretics or with infections.
• Overflow incontinence results from the bladder not emptying, often due to urethral blockage from BPH.
• A symptom across all types of urinary incontinence is involuntary leakage of urine.
• Risk factors include being geriatric (increased frequency, decreased bladder capacity, nocturia) and history of pregnancy with vaginal delivery.
• Teaching points include decreasing coffee intake, stopping smoking, preventing constipation and using the bathroom to void every 4-6 hours.

Lower UTI: Cystitis & Urethritis

• The pathophysiology of both cystitis and urethritis involves infection from bacteria, fungus, parasite, chemical irritant, foreign body, or trauma.
• Cystitis specifically involves a bladder infection associated with stasis of urine.
• Urethritis is caused by STIs, immunosuppression, poor hygiene, or impaired protective mechanisms.
• Protective mechanisms against UTIs include one-way urine flow, epithelial cells lining the urinary tract, and the acidity of the environment.
• Signs and symptoms include frequency, urgency, dysuria, pink or cloudy urine, and pelvic pain.
• In geriatric patients, delirium can be a symptom of a UTI.
• Labs to pull include a complete blood count (CBC) and a comprehensive metabolic panel (CMP).
• Medications to administer include Trimethoprim/Sulfamethoxazole (antibiotic) and Phenazopyridine (urinary analgesic).
• Patient teaching for Phenazopyridine includes drinking 8 glasses of water per day, using sunscreen, and being aware that urine will turn orange.

Acute Pyelonephritis

• The pathophysiology involves obstruction or urethral reflux leading to contaminated urine back-flowing into the kidney, potentially caused by renal calculi.
• Signs and symptoms include costovertebral angle tenderness, fever, chills, nausea/vomiting, and dehydration.
• Diagnosis and treatment involve IV pyelogram, monitoring BUN/Creatinine (contrast), and IV fluids with 0.9% NaCl (for dehydration risk).
• Monitor creatinine levels, with levels increased greater than 2 times the normal amount.

Chronic Pyelonephritis

• The pathophysiology involves chronic reflux of contaminated urine, leading to a smaller/inflamed kidney, or obstruction from renal calculi causing urinary stasis/bacteria growth; the kidney becomes scarred/atrophied.
• Signs and symptoms are vague and inconsistent.
• Diagnosis/treatment involves BUN/Creatinine monitoring, urinary analgesics, antipyretics, antibiotics, and input/output monitoring (minimum 1500mL per day, intake 3-4L).

Renal Calculi (Nephrolithiasis/Urolithiasis)

• Increased concentration of particles in the urine leads to stone formation, causing obstruction.
• Signs and symptoms include renal colic, dull or localized flank pain, nausea/vomiting, and hematuria.
• Treatment involves opioids for pain and drinking 2 glasses of water at bedtime.
• Prevention includes avoiding activities with excessive sweating/dehydration, decreasing protein intake, and avoiding spinach/strawberries/wheat bran (oxalate).

Acute Glomerulonephritis

• The pathophysiology is an infection (virus/bacteria) where the immune system attacks the glomeruli walls.
• Glomerular membranes become more permeable, increasing the glomerular filtration rate (GFR).
• Signs and symptoms include coffee-colored urine, headache, hypertension, periorbital edema, and shortness of breath (SOB).
• Treatment involves monitoring vital signs every four hours, daily CBC/CMP, fluid restriction to prevent overload, eating carbs for energy, and reducing protein breakdown.

Chronic Glomerulonephritis

• Kidneys become hard and small due to chronic proteinuria and hypertension, causing renal damage (scarring/atrophy) that leads to chronic kidney disease (CKD).
• Signs and symptoms include weight loss, decreased strength, nocturia, hyperkalemia, metabolic acidosis, headache, anemia, and pericardial rub.
• Treatment/diagnosis involves a high protein diet, diuretics, antihypertensives, dialysis, and strict input/output monitoring.

Nephrotic Syndrome

• Increased glomerular permeability and massive proteinuria damages the glomerular membrane; systemic diseases like lupus, infection, cancer, diabetes mellitus (DM), and vasculitis can cause this syndrome.
• Edema occurs due to loss of albumin causing a decrease in oncotic pressure and hepatocytes increasing lipid synthesis causing hyperlipidemia.
• Signs and symptoms include increased risk for thrombus and generalized edema.
• Monitor skin integrity (sacral area) and for thrombus/PE; urine analysis: Protein and WBC to treat/diagnose this.
• Medications used include ACE inhibitors, diuretics, and lipid-lowering medications.

Polycystic Kidney Disease

• Either recessive or dominant inheritance pattern, with the dominant form spreading to other structures and organs.
• Distinguish between recessive and dominant forms via liver biopsy.
• Recessive form: respiratory distress, enlarged kidneys, systemic HTN.
• Dominant form: Present at 40-50 years old; urine concentration decreased; HTN; Proteinuria; Hematuria; Pain.
• Treatment: Supportive care; Apply heat to the abdomen to decrease discomfort, prevent dehydration with fluid intake, avoid NSAIDS

Acute Kidney Injury (AKI)

• Acute loss of renal function due to decreased perfusion from MI, DM, HTN, BPH, or nephrotoxic substances.
• Pre-renal: Peripheral vascular disease decreases blood flow TO kidney.
• Intra-renal: Nephrons constricted/blocked, disruption INSIDE kidneys.
• Post-renal: OBSTRUCTION.
• Cardiac infarction can cause pre-renal injury due to decreased perfusion to the kidney.
• RAAS system attempts to compensate with fluid and dilation.
• Untreated/uncorrected pre-renal injury can progress to intra-renal injury.
• Signs and symptoms include electrolyte/ABG imbalances.
• Oliguric phase: no urine.
• Diuretic phase: hypovolemia; urine not concentrated.
• Recovery phase: electrolytes are normalizing like potassium.
• Acute tubular necrosis: Damage to tubules seen in intra-renal injuries; Vasoconstriction.
• Risks involve Hemorrhage/ volume decreased, so less perfusion to kidneys, causes injury.
• Treatment involves limiting NSAIDs, contrast, and nephrotoxic medications.
• Strict I&O and a diet high in carbs with no potassium or phosphorous are also included in the treatment.

Chronic Kidney Disease (CKD)

• Damage to the nephrons causing them not to work.
• Other nephrons try to compensate, but ultimately fail. seen in those with uncontrolled HTN, DM, Smoking, Long-term impaired circulation.
• Increased risk for Anemia d/t decreased production of erythropoietin (Comes from kidneys and sent to bone marrow to produce RBCS).
• End stage renal disease involves Stage 5: Bone disorders d/t deficiency of Vitamin D, Increased Phosphorous, and Decreased calcium.
• Signs and symptoms are Edema; Pulmonary congestion; Pericardial friction rub.
• Types of dialysis are Hemodialysis; Peritoneal Dialysis; Continuous renal replacement therapy.
• Nursing interventions are Monitor weight gain; Notify provider of decreases urinary output.
• Hold BP/Cardiac meds for dialysis be dialysis will remove them
• Teaching points: No potassium/phosphorous; High carb diet.
• Medications are Diuretics; Calcium binders; Antihypertensives and ketorolac (nephrotoxic).

Kidney Labs

• BUN (10-20): INCREASED.
• Creatinine (0.6-1.2 & 0.5-1.1): INCREASED.
• GFR (90-120): DECREASED.
• Hgb (14-18; 12-16): LOW/ANEMIA.
• RBC (4.7-6.1; 4.2-5.4): LOW.
• Triglycerides (40-60; 35-135): HIGH.
• Potassium (3.5-5): INCREASED.
• Calcium (9-10.5): LOW.
• Phosphorous (2 – 4.5): INCREASED.

Geriatric Considerations for GU

• Medications may not be metabolized properly due to decreased filtration.
• Pelvic muscle exercises (KEGELS) and scheduled bathroom breaks are helpful.

Stomatitis

• Idiopathic, ulcerations of the oral mucosa, bacterial or viral (HSV).
• Commonly seen in Chemo patients, Radiation therapy, Autoimmune disorders.
• Signs and symptoms are Pain and Ulcers in mouth.
• Monitor swallowing and ability to chew.
• If patient cannot eat - NG tube or PICC for TPN
• Treatment: Magic mouthwash

GERD

• Lower esophageal sphincter is not closing efficiently.
• Caused by Restrictive clothes; Weight gain; Smoking; Pregnancy; Caffeine/ Alcohol; Fatty food.
• Signs and symptoms are Heartburn; Chest pain; Dysphagia; Barrett's esophagus.
• Treatment: Omeprazole (Proton pump inhibitor) or Ranitidine (H2 blocker).
• Teaching includes Omeprazole: long-term use has concerns for fractures; may have diarrhea/HA (DO NOT CRUSH).
• Stop smoking/drinking, Eat a low-fat diet, No milk/Peppermint/Soda and maintain Weight loss

Hiatal Hernia

• IDIOPATHIC.
• Loosening of muscular band around esophagus/diaphragmatic junction.
• Part of the fundus is above the diaphragm.
• Signs and symptoms are Dysphagia or GERD symptoms.
• Life-threatening is strangulation: Belching/Regurgitation
• Diagnosis: Barium swallow study or EGD
• Treatment: Surgery; Diet restrictions

Esophageal Varices

• Enlarged veins of esophagus due to portal hypertension.
• Variceal bleeding shows as Hematemesis, Melina, Anemia or Hemorrhage (shock).
• Treatment is IV Octreotide (anti-diarrheal; splanchnic vasoconstriction).

Gastritis

• Inflammation of stomach lining from aspirin, alcohol, H. Pylori, irritation.
• Signs and symptoms are Asymptomatic OR Nausea/vomiting, postprandial discomfort during/after meals.
• Avoid NSAIDS/ASA FOR PAIN.
• Education for patients includes: Physical activity for reducing stress, Avoid alcohol/caffeine, Notify PCP if stool is dark be possible GI bleed.

Gastroenteritis

• Acute inflammation of the stomach and small intestine.
• Diarrhea, Pain, N/V, Fever, Malaise, Abdominal discomfort are symptoms.
• Treat it like a stomach bug - IVF and bowel rest.

Peptic Ulcer Disease

• Stomach acid in the upper GI damages lining of digestive tract due to the Breakdown of epithelial mucosal barrier (duodenal/gastric area).
• Pain, Burning, Nausea, Hematemesis (concerning GI bleed), Dyspepsia when stomach is empty are symptoms.
• Notify the provider when there is coffee ground emesis or NG tube drainage or if patient has heart flutter 30min after eating (Dysrhythmia).
• Diagnose this with an EGD procedure (endoscope down the esophagus to view upper gastric wall/stomach).

Ulcerative Colitis

• Inflammatory bowel disease that only affects the colon.
• Inflammation starts at the base of Lierberkuhn and leads to abscess formation in epithelia of crypts.
• This causes exudative diarrhea.
• Patients are at risk for Colon cancer.
• A serious complication is Toxic Megacolon: swelling/inflammation of the colon and it stops working/could rupture.
• Symptoms are Abdominal pain, Bloody diarrhea, and Rectal bleeding.
• Diet needs to be Low Fiber, High Protein, and High Calorie.
• treatment would be Corticosteroids, Immunomodulators or Antibiotics.
• Monitor CBC (for bleeding), Stool (occult blood), or Albumin being decreased in labs.

Crohn's Disease

• Inflammatory bowel disease that affects entire GI tract.
• Presents with a Cobblestone-like appearance through GI tract.
• Also seen with Ulcers, Fissures, Fistulas, and Abscesses.
• Symptoms are Malnutrition (anemia/malaise), Toxic megacolon, Abdominal pain, Diarrhea (bloody but not as bad as UC), Arthritis and Fever.
• Treatment is Corticosteroids, Antibiotics, and TPN.
• Monitor labs: WBC (elevated) or ESR (Elevated).
• Complications normally include decreased potassium or Abnormal electrolytes.

Enterocolitis (Antibiotic Associated & Pseudomembrane Colitis)

• C. Diff.
• Large intestine exposed to bacterial toxins causes inflammation/mucosal necrosis.
• Elevated WBC, Fever, Abdominal pain, Sepsis or Perfume watery foul-smelling diarrhea are symptoms.
• Treat with Contact Precaution or Antibiotics.

Appendicitis

• Inflammation of the vermiform appendix due to a hard strong mass of feces that causes obstruction.
• Symptoms are Fever, Diarrhea, Nausea, Migrating pain at McBurney's point (RLQ).
• Maintain hydration and educate patient to go to ER.
• Treatment is Appendectomy or Antipyretic (fever).
• Meds are Antibiotics, IVF or Opioids and NO LAXATIVES.

Diverticulitis / Diverticulosis

• Creates polyps in the intestinal tract and Results in constipation.
• Strongly related to low fiber intake & high pressure in the intestine.
• Diverticulitis: Something gets stuck in the polyp and causes inflammation, infection, and rupture.
• Left LQ pain; Fever; Elevated WBC; Constipation/Diarrhea are symptoms.
• Complications are Sepsis, Obstruction or Perforation.
• Meds are Antibiotics, Laxatives and Fiber.
• Prevention: Drink 8 glasses of water daily, Increase soft/cooked veggies and NO NUTS, NORN, OR SEEDS.
• Psyllium daily to increase bulk/fiber and avoid constipation.

Irritable Bowel Syndrome (IBS)

• Non-inflammatory, Idiopathic, No identifiable pathological process.
• Either constipation or diarrhea.
• Signs and symptoms are Constipation, Diarrhea, Nausea or Mucus in stool.
• Abdominal pain is relieved with defecation.
• Medications are Antidiarrheal, Fiber (psyllium), Antibiotics, Probiotics or Dicyclomine (antispasmodic) -> food will taste different; relaxes intestine muscles.
• Education to the patient: Monitor diet for triggers, Sleep, Exercise, No fluid with meals. Stress control and consider adding an antidepressant.

Intestinal Obstruction

• Impacted feces or blockage that can be in small or large bowel.
• Mechanical = obstruction from scar tissue (hernia, tumor, intussusception, etc.).
• Functional = loss of propulsive ability (occurs after surgery).
• Abdominal distention, Abdominal pain, and Fever are symptoms.
• Increased bowel sounds at first and then NO bowel sounds are also symptoms.
• Large bowel obstruction leads to Lower abdominal cramps.
• Treatment: Stop tube feeding or PO feeding due to the obstruction.
• Bowel rest and IVF to push fluid to break up hard stool.
• NG tube on low intermittent suction.
• Measure abdominal girth.
• Prepare them for surgery if the patient is not responding to treatment.
• A patient complaining of constipation and has a fever with tachycardia might be experiencing an Obstruction that has perforated or Intestinal strangulation.

Celiac Disease

• Intolerance of gluten triggered by gliadin and Genetically pre-disposed.
• Intestinal villi starts to atrophy and causes malabsorption.
• Mainly see with FEMALES!!!
• Symptoms include Weight loss, Malnutrition, Diarrhea/Constipation, Joint pain and Tooth enamel loss.
• Educate your patient on avoiding foods with gluten or other triggering foods.

Dumping Syndrome

• Impaired/rapid gastric emptying into the small intestine causing malabsorption 30 min after eating.
• Glucose IS absorbed, so the patient secretes insulin and causes hypoglycemia within 1-3 hours.
• Signs and symptoms are Abdomen pain, Diarrhea, Hypovolemia (fluid shifting from blood to intestine) or Hypoglycemia lasting 1-3 hours after eating.
• Monitor hypoglycemia and treat as indicated
• No fluid with meals and No/low high carbs

Short-Bowel Syndrome

• Severe diarrhea causing malabsorption of nutrients (water, electrolytes, carbs, protein, vitamins, minerals) due to surgical removal of parts of the small intestine.
• Symptoms are dependent on the location of intestine that was removed.
• Monitor nutritional deficits due to malabsorption related to the removal of part of the small intestine.
• Might need parenteral nutrition.
• Medications are: Senna (avoid milk/antacids within one hour of taking)Octreotide (antidiarrheal/splanchnic vasoconstriction), Dicyclomine (antispasmodic; food will taste different) or Omeprazole (decreases gastric acid; risk for hip fracture, diarrhea, HA).
• Use GT feeds by Infusing formula at a prescribed rate. Slowly 20mL/hr or 50mL/hr and slow feeds if the patient starts experiencing cramping.