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Questions and Answers
What is the primary goal in managing acute diverticulitis?
Which of the following diagnostics is NOT typically used for diagnosing diverticulitis?
Which medication is commonly prescribed to manage symptoms of Parkinson's disease?
What complication can arise from a perforation during acute diverticulitis?
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Which dietary recommendation is advised for prevention of diverticulitis?
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In managing recurrent diverticulitis, what is a potential surgical option?
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Which symptom is NOT associated with Parkinson's disease?
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Which lifestyle change is recommended for managing diverticulitis?
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What is the most common complication associated with hemodialysis?
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Which of the following dietary restrictions is crucial for patients undergoing dialysis?
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Which of the following is NOT a typical symptom of chronic kidney disease?
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What describes the initial steps in managing persistent hyperkalemia in a dialysis patient?
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In which situation would a peritoneal dialysis patient be advised to avoid certain activities?
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Which complication of dialysis is characterized by the rapid removal of solutes, leading to neurological symptoms?
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What type of diet is typically recommended for patients with chronic kidney disease?
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What is the main goal of peritoneal dialysis?
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What is the recommended action if a dialysis patient is experiencing muscle cramps during treatment?
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Which statement about fluid management in dialysis patients is true?
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What is a potential side effect of using tolvaptan for treating acute rapid cases in polycystic kidney disease?
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Which of the following is a major complication associated with peritoneal dialysis?
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Which of the following electrolytes is most likely to become imbalanced in patients with chronic kidney disease?
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What condition is characterized by an involuntary loss of urine due to increased pressure on the bladder?
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Which of the following treatments is primarily used for urge urinary incontinence?
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Which of the following is NOT a common cause of urinary retention?
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In the context of urinary incontinence, what does the acronym DRIP stand for?
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Which intervention is commonly used for preventing urinary retention in patients unable to void?
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Which type of urinary incontinence is associated with an overflow of urine due to reduced bladder contractility?
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Which diagnostic test demonstrates the presence of post-void residual volume (PVR) in the bladder?
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Which intervention can be helpful for both acute urinary retention and in case of dysfunction?
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What type of urinary incontinence is most common in older adults leading to difficulty reaching the bathroom in time?
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What is an appropriate first step in managing overflow urinary incontinence?
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Which treatment is effective in managing stress urinary incontinence, especially after prostate surgery?
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Which of the following is a complication that can arise from urinary retention?
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What is a dietary consideration for patients with chronic urinary incontinence?
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Which symptom is characteristic of multiple sclerosis affecting the urinary system?
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Study Notes
Urinary Retention
- Post void residual (PVR) is used to determine if the bladder has been completely emptied after urination.
- Normal PVR is 50-75 mL.
- PVR greater than 200 mL should be further evaluated.
- Chronic urinary retention is the inability to fully empty the bladder despite attempting urination.
Polycystic Kidney Disease (PKD)
- PKD is caused by the development of multiple cysts in the kidneys.
- PKD is a genetic disorder.
- Symptoms include hypertension (HTN), hematuria, pain/heaviness in the back, abdomen, or sides, abdominal swelling, and frequent UTIs.
- PKD can also manifest with cerebral aneurysms, cysts in the liver, or other organs, and diverticulosis.
- Diagnosis is often based on family history.
- Diagnostic testing includes urinalysis (showing blood or bacteria), BUN, creatinine, electrolytes, urine cultures, and ultrasounds.
- There is no cure for PKD, and it often progresses to chronic kidney disease (CKD).
- Treatment options include:
- Tolvaptan for acute rapid cases.
- Prevention and treatment of UTIs.
- Nephrectomy (surgical removal of the kidney).
- Dialysis and kidney transplant.
- Genetic counseling.
- Interventions include:
- Renal diet (if renal function is impaired) with low protein, potassium, magnesium, and phosphorus.
- HTN control.
- Fluid restriction (if renal failure).
- Avoiding NSAIDS.
Chronic Kidney Disease (CKD)
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CKD is a progressive, irreversible loss of kidney function.
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Leading causes of CKD are diabetes and hypertension.
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Symptoms include:
- Edema (fluid retention).
- Loss of appetite, nausea, anorexia, and gastrointestinal (GI) bleeding.
- Fatigue.
- Dry skin.
- Muscle cramps.
- Foamy urine.
- Increased frequency of urination.
- Metabolic acidosis.
- Fluid and electrolyte imbalances, including:
- Hypermagnesemia.
- Hyperkalemia (most serious disorder!).
- Acute hyperkalemia is treated with intravenous glucose and insulin and kayexalate for cation exchange (sodium instead).
- Dialysis is the most effective treatment for hyperkalemia.
- Hyponatremia or hypernatremia.
- Hypocalcemia.
- Chronic anemia.
- Personality and behavioral changes.
- Hyperglycemia and hyperinsulinemia.
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CKD is staged based on Glomerular Filtration Rate (GFR):
- Stage 1: Kidney damage with normal renal function (GFR >90).
- Stage 2: Mild reduction of renal function (GFR 60-89).
- Stage 3: GFR reduction less than 60.
- Stage 4: Severe reduction in GFR (15-29).
- Stage 5: Renal failure (GFR less than 15).
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CKD is diagnosed through:
- Persistent proteinuria.
- GFR less than 60.
- Urinalysis, creatinine clearance, serum creatinine, and BUN (as GFR decreases, BUN and serum creatinine increase).
- Renal ultrasound and CT scan.
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CKD treatment focuses on:
- Management of diabetes and hypertension (including ACE inhibitors and ARBs with caution due to potential for increased potassium).
- Prevention of cardiovascular disease.
- Calcium and Vitamin D supplementation.
- Iron supplementation for anemia.
- Correction of electrolyte imbalances.
- Protein, sodium, fluid, potassium, and phosphate restriction in the diet.
- Adjustment of existing drug dosing for renal impairment.
End-stage Renal Disease (ESRD)
Dialysis
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Dialysis is used to correct fluid and electrolyte imbalances and remove waste products in kidney failure.
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Dialysis is initiated when:
- Uremia (excess waste in the urine) cannot be managed conservatively.
- GFR is less than 15.
- Metabolic acidosis.
- Volume overload.
- Severe hyperkalemia.
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Types of dialysis:
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Peritoneal Dialysis:
- Involves filling, dwelling, and draining the peritoneal cavity multiple times a day.
- Dextrose is commonly used for ultrafiltration.
- It is a simple, home-based form of dialysis with a less strict diet.
- Sodium and water restriction are recommended.
- Monitor abdominal girth and outflow.
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Complications:
- Site infection that can lead to peritonitis:
- Monitor for fever, rebound abdominal tenderness, cloudy outflow, nausea, and vomiting.
- Diarrhea and vomiting (treat with antibiotics).
- Distension (treat with antibiotics).
- Hernias (due to increased abdominal pressure).
- Lower back problems (due to increased pressure).
- Bleeding due to initial catheter placement or active intraperitoneal bleeding.
- Decreased lung expansion due to atelectasis (collapse of a lung) or pneumonia (elevate head of bed, reposition, breathing exercises).
- Protein loss (monitor nutrition).
- Site infection that can lead to peritonitis:
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Hemodialysis:
- Filters out excess fluid and waste from the blood and returns clean blood.
- Requires rapid blood flow providing access to a large blood vessel.
- Typically performed for 3-4 hours three times per week.
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Complications:
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Hypotension (due to hypovolemia, decreased cardiac output, vision changes, chest pain, lightheadedness, nausea):
- Treatment includes: decreasing the volume of fluid removed and administering intravenous normal saline solution (NSS).
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Muscle Cramps (due to hypovolemia, low blood pressure, and increased ultrafiltration):
- Treatment includes decreasing ultrafiltration and administering intravenous fluids.
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Loss of Blood (due to blood not being rinsed, accidental tube separation, rupture, or heparin administration):
- Treatment includes rinsing all blood and avoiding excessive heparin.
- Hepatitis (typically hepatitis C, sometimes hepatitis B, due to infection).
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Disequilibrium Syndrome
- Occurs frequently in new clients, caused by rapid removal of solutes.
- Symptoms include nausea, vomiting, seizures, and heart attack.
- Sepsis, shock, depression, non-adherence.
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Hypotension (due to hypovolemia, decreased cardiac output, vision changes, chest pain, lightheadedness, nausea):
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Before Dialysis:
- Always assess fluid status, including weight, blood pressure, peripheral edema, heart and lung sounds.
- The difference between the last post-dialysis weight and the current pre-dialysis weight determines how much fluid will be removed.
- Assess vascular access and temperature.
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During Dialysis:
- Assess vital signs every 30-60 minutes.
- Daily weights.
- Monitor labs—including BUN, creatinine, and complete blood count (CBC)—before, during, and after dialysis.
- Hold hypertension medications until after treatment.
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Protein Restriction/Reduction is recommended.
Cirrhosis
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Symptoms: Jaundice, palmar erythema, spider angiomas, thrombocytopenia (decreased platelets, increased bleeding), ascites, gastric and esophageal varices, edema, peripheral neuropathy.
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Treatment:
- Increased protein and carbohydrate diet with protein supplements.
- Diuretics for edema.
- Lactulose for hepatic encephalopathy.
- Draining fluid for abdominal ascites.
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Complications:
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Hepatic encephalopathy:
- The liver cannot convert ammonia to urea, causing ammonia buildup in the body, which crosses the blood-brain barrier.
- Symptoms include difficulty constructing simple figures, flapping hand tremors, sweet/musty breath, coma, and sleep disturbances.
- Neuro checks are performed every 2 hours, and lactulose is administered.
- Hepatorenal syndrome.
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Gastric/esophageal varices:
- Caused by portal hypertension, which dilates the veins.
- Esophageal varices are a serious complication.
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Hepatic encephalopathy:
Constipation
- Reduced B6 intake can contribute to constipation.
- Late symptoms of constipation include reduced arm swinging, shuffling gait, orthostatic hypotension, dyskinesia, and slow speech.
Dementia & Alzheimer's
- Alzheimer's is a type of dementia, which is an overarching decline in cognitive ability.
- Dementia is characterized by irreversible deterioration of cognition.
- Symptoms of dementia include:
- Short-term memory loss
- Difficulty with communication, focus, reasoning, or visual perception
- Psychosis (hallucinations, delusions, paranoia)
- Dementia symptoms are worsened by alcohol or medical disorders.
- Alzheimer's is a combination of aging, family history, cardiovascular health, and head trauma.
- Symptoms of Alzheimer's include:
- Reading difficulty
- Poor direction and judgment
- Misplacing belongings
- Visual changes
- Difficulty communicating
- Diagnostics for dementia and Alzheimer's:
- Mini-mental state exam
- EEG
- CT or MRI
- PET scan
- Lab tests
- Interventions for dementia and Alzheimer's:
- Avoid stimulants
Multiple Sclerosis
- Multiple sclerosis (MS) is characterized by plaques or lesions on the spinal cord.
- MS can be caused by infection, smoking, pregnancy, or poor health.
- Symptoms of MS can be slow and gradual or rapid.
- There are periods of remission and exacerbations.
- Symptoms include:
- Blurred vision
- Red-green color distortion
- Extremity muscle weakness and lack of balance
- Dysarthria, ataxia, and nystagmus
- Spastic bowel and bladder
- Painful intercourse
- Short-term memory loss
- Diagnostics for MS:
- Two inflammatory demyelinating lesions in two different locations within the CNS
- Medications for MS:
- Immunomodulators
- Immunosuppressants
- Glucocorticoids (prednisone and methylprednisolone)
- Interventions for MS:
- Physical, occupational, and speech therapy
- Psyllium for bowel dysfunction
- Gabapentin for neuropathic pain
Myasthenia Gravis
- Myasthenia gravis (MG) is an autoimmune neuromuscular disorder.
- Antibodies attack skeletal muscle receptors.
- MG can be exacerbated or caused by rheumatoid arthritis medication.
- Symptoms of MG can first appear as ocular issues (drooping eyelids). It can progress to generalized weakness.
- Skeletal muscle weakness starts in the face and moves to the extremities.
- Muscles become exhausted by the end of the day.
- Diagnostics for MG:
- AChR antibodies present in blood
- EMG test showing decreased response to stimulation
- Chest CT routinely to evaluate for a mediastinum tumor
- Medications for MG:
- Pyridostigmine: improves neuromuscular transmission, initial choice of treatment.
- Neostigmine: shorter-acting version of pyridostigmine.
- Interventions for MG:
- Complications:
- Myasthenic crisis: muscle weakness around the lungs and respiratory failure due to infection.
- Give IVIG (calms down the immune system).
- Cholinergic crisis: taking too much MG medication causing bradycardia, sweating, and small pupils.
- Stop the medication.
- Myasthenic crisis: muscle weakness around the lungs and respiratory failure due to infection.
- Removing the thymus gland (it produces antibodies) can be helpful for symptoms.
- Complications:
Trigeminal Neuralgia
- Trigeminal neuralgia is caused by vascular compression of the trigeminal nerve.
- It affects sensory and motor branches of the CNS.
- Two types of trigeminal neuralgia:
- Type 1: Severe, excruciating episodes of stabbing pain; facial twitching/grimacing, facial sensory loss, trigger zone that requires light touch, aggravating stimuli (hot/cold air, yawning, eating, brushing teeth).
- Type 2: Facial pain of spontaneous onset with more than 50% constant pain.
- Diagnostics for trigeminal neuralgia:
- History, physical, and neurological exams.
- Medications for trigeminal neuralgia:
- Antiseizure meds (type 1)
- Tricyclic antidepressants (type 1)
- Analgesics/opioids (type 2)
- Interventions for trigeminal neuralgia:
- Evaluate degree of pain and effects on lifestyle.
- Discuss the use of complimentary alternative medicine.
- Easy to chew food, mild in temperature and spice.
- Meticulous oral hygiene and semiannual dental visits.
- Protective eye shield.
- Use of an electric razor.
Guillain-Barré Syndrome (GBS)
- GBS is an autoimmune disease that attacks the peripheral nervous system (PNS).
- GBS is a lower motor neuron disorder.
- Symptoms of GBS:
- Generalized weakness
- Motor neuropathy
- Areflexia
- Distal limb paresthesias
- Facial and oropharyngeal weakness
- Dysphagia
- Facial palsy
- Flaccid bladder/bowel
- Diagnostics for GBS:
- EMG
- Lumbar puncture (elevated CSF protein level)
- Interventions for GBS:
- Watch for blood clots and deep vein thrombosis (DVT).
- Pain management.
Amyotrophic Lateral Sclerosis (ALS)
- ALS is a disease where the brain cannot control muscle movement.
- No muscle nourishment occurs with ALS.
- Symptoms of ALS:
- Gradually weakening muscles and atrophy
- Paralysis with sensations intact
- Slurred speech
- Muscle cramping
- Fatigue of extremities
- Hyperreflexia
- Difficulty swallowing
- Upper motor neuron damage causing spasticity.
- Lower motor neuron damage causing flaccidity.
- Diagnostics for ALS:
- MRI of neck, brain, and spinal cord to rule out other diagnoses.
- EMG: nerve conduction
- Muscle biopsy
- Myelogram
- Medications for ALS:
- Riluzole and edaravone
- Riluzole: reduces damage to motor neurons.
- Edaravone: neuroprotective.
- Baclofen for muscle cramps.
- Stool softeners.
- CNS stimulants for fatigue.
- Tricyclic antidepressants for excessive saliva, pain, and depression.
- Interventions for ALS:
- Normal things for when a patient is essentially bedbound and cannot move.
- PT and OT.
- Tracheotomy and ventilation if needed.
- Respiratory infection is the most fatal complication.
Urinary Incontinence (UI)
- UI is involuntary loss of urine.
- Types of UI:
- Stress: increased pressures on the bladder, common in women with weak pelvic floor, post-menopausal women, and men after prostate surgery.
- Treatments: pelvic floor exercises, surgery.
- Urge: overactive bladder, abnormal contractions cause strong urge to pee followed by leakage.
- Treatments: anticholinergics, absorbent products.
- Mixed: stress + urge, high abdominal pressure + overactivity.
- Overflow: decreased contractility or bladder obstruction.
- Treatments: catheter, alpha blockers.
- Functional: due to age or physical mobility, unable to get to the bathroom in time.
- Treatments: modify environment, better timing, better clothing, adaptive equipment.
- Stress: increased pressures on the bladder, common in women with weak pelvic floor, post-menopausal women, and men after prostate surgery.
- Diagnostics for UI:
- Focused history and physical exam
- Urinalysis
- PVR (post-void residual)
- Urinalysis and urine culture
- Bladder scan
- Medications for UI:
- Based on the type of incontinence.
- Interventions for UI:
- Surgery to tighten the pelvic floor.
- Clean intermittent catheterization.
Urinary Retention (UR)
- UR is the inability to empty the bladder.
- Causes of UR:
- Obstruction
- Neuro impairment
- Detrusor muscle cannot contract (diabetes, over distension, infection, renal stones, pregnancy).
- Diagnostics for UR:
- Bladder scan
- Urinalysis
- PVR
- Medications for UR:
- Anticholinergics to improve storage capacity
- Alpha-adrenergic blockers (flomax) to reduce resistance.
- Interventions for UR:
- Surgery to remove obstruction (TURP)
- Increase muscle strength (sacral neuromodulation)
- Scheduled voiding
- Double voiding
- Intermittent/indwelling catheterization
- Acute: emergency, lean towards indwelling catheter.
- If unable to void: drink caffeinated drinks to increase urgency, warm baths or showers.
Diverticulitis
- Diverticulitis is a condition where diverticula in the colon become inflamed.
- Diverticula are small pouches that form in the lining of the colon.
- Diverticulosis is the presence of diverticula without inflammation.
- Complications of diverticulitis:
- Abscess: collection of pus.
- Perforation: hole in the colon.
- Peritonitis: inflammation of the abdominal lining.
- Intestinal obstruction: blockage of the intestines.
- Diagnostics for diverticulitis:
- CBC (complete blood count)
- Colonoscopy or sigmoidoscopy
- Abdominal ultrasound
- CT of the abdomen or pelvis
- Digital rectal exam (physical exam)
- Management of diverticulitis:
- Prevention:
- High fiber and decreased fat/red meat diet.
- Add fiber supplements.
- Physical activity (not weight lifting).
- Lack of restrictive clothing, bending, vomiting, and lifting.
- Acute diverticulitis:
- Goal: bowel rest and reducing inflammation.
- Clear liquids, bed rest, analgesia.
- Hospital admission (if severe).
- Recurrent diverticulitis:
- Surgical resection or temporary colostomy.
- Prevention:
Parkinson's Disease
- Parkinson's disease is a progressive neurological disease with no cure.
- Parkinson's occurs due to an acetylcholine and dopamine imbalance caused by the loss of basal ganglia cells.
- Symptoms of Parkinson's Disease:
- TRAP: Tremors at rest, Rigidity, Akinesia, Postural instability.
- Akinesia can also cause bradykinesia and dyskinesia.
- Sleep disorders, pain, urinary retention, erectile dysfunction, memory changes.
- Medications for Parkinson's Disease:
- Antiparkinsonian drugs (levodopa with carbidopa) that level out the neurotransmitters.
- Administer medication on an empty stomach.
- Interventions for Parkinson's Disease:
- Encourage independence as much as possible.
- Optimize well-being.
- Report uncontrolled movements and monitor for dyskinesia.
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