Med surg exam 3

• Common HAI (Hospital Acquired Infection), Urinary Tract Infections (UTIs)

UTI Etiology

• Escherichia coli (E. coli) bacteria from feces is a common cause
• Lower UTIs: urethritis, prostatitis, and cystitis
• Upper UTIs: pyelonephritis, urethritis

UTI Risk Factors

• Risk increases with aging, mostly over 65
• Contamination from perineal and urethral areas increases risk
• Faulty valves causing reflux of urine, whether congenital or acquired
• Anatomical differences may increase risk
• Instrumentation infection can occur, most commonly from urinary catheters
• History of UTIs increase risk
• Urinary stasis promotes bacterial growth

UTI Signs and Symptoms

• Voiding urgency and frequency
• Burning sensation when voiding (dysuria)
• Urine appears Cloudy and foul-smelling
• Hematuria (blood in urine)
• Older adults may experience confusion, fatigue, and delirium

Types of UTIs

• Urethritis: inflammation specifically in the urethra
  • Avoid bubble baths
  • Phenazopyramide (Pyridium) treats dysuria, colors urine orange
• Cystitis: inflammation of the bladder wall, commonly caused by E. coli
  • Pelvic pain and pressure occur
  • Medications include nitrofurantoin (Macrobid), sulfamethoxazole (Bactrim), and fosfomycin (Monurol)
  • It is important to educate to take the entire course of prescription to prevent bacterial resistance
• Encourage fluids to flush the bladder
• Pyelonephritis: infection of one or both kidneys
  • Costovertebral tenderness, high fever, chills, and nausea/vomiting are signs
  • Frequent kidney infections can cause scarring and loss of kidney function
• Urosepsis: can result in septic shock and death
  • Prompt treatment is essential
  • Older adults are at a greater risk of Urosepsis

Urological Obstructions

• Urethral Strictures: narrowing of the urethral lumen due to scar tissue
  • Catheterization is needed to drain obstructed urine
  • Mechanical dilation, urethroplasty (surgical repair), and stent placements are options
• Renal Calculi (Kidney Stones): form in kidneys (nephrolithiasis) or ureters (ureterolithiasis)
  • Concentrated urine, leading to crystal formation from excess calcium
  • Low citrate or substances that inhibit stone formation
  • Most stones are made of calcium oxalate
  • Chronic high pH, excessive sweating, medications (aspirin, topiramate, certain supplements), and low calcium diets are causes
  • This is more common in men
• Nephrolithiasis causes costovertebral angle pain and hematuria
• Ureterolithiasis causes severe colicky pain, flank pain radiating to genitalia, urge to void, frequency, dysuria, hematuria, nausea/vomiting
  • Bladder stones cause hematuria and oliguria
• Hydronephrosis is a complication

Renal Calculi (Kidney Stones) Prevention

• Drink 2-3 quarts of fluids daily for hydration
• Avoid sweet drinks and grapefruit juice
• Encourage ambulation to reduce bone calcium reabsorption
• Urocit-K (Potassium Citrate) restores chemicals in urine

Renal Calculi (Kidney Stones) Therapeutic measures

• For stones less than 10mm, hydration and medications are used
• Be sure to strain all urine
• Limit sodium, fat, and protein intake
• Cystoscopy: “wire basket removal"; used for small stones, cystolitholapaxy for larger stones
• Ureteroscopy: insert tube into bladder and along ureter to view stone
• Lithotripsy: uses sound shock waves or laser energy to break stone into small fragments
• Percutaneous nephrolithotomy: performed for large stones that cannot be removed; with temporary nephrostomy tube or stent

Hydronephrosis

• Distension of renal pelvis and calices, but is treatable once detected
  • Results from ureteral stricture, renal calculi, tumors, or enlarged prostate
  • Unrelieved pressure causes urine-filled sacs, damaging blood vessels and renal tubules
  • Flank and back pain, UTI symptoms (urgency, frequency, dysuria) are symptoms
  • Treatment includes relieving urinary retention with stent placement, nephrostomy cube and measuring intake and output

Tumors of Renal System

Bladder Cancer: most common cancer of the urinary tract

• Originates in inner lining (urothelium), defined as “transition cell cancers"
• Superficial cancer affects only inner lining of the bladder
• Invasive cancer spreads to muscle wall
• May metastasize to liver, bones, and lungs

Bladder Cancer Etiology

• Cigarette smoking
• Industrial pollution

Bladder Cancer Signs and Symptoms

• Painless hematuria is the beginning
• Blood clots/frank hematuria, bladder irritability, urine retention
• Fistula formation
• Pelvic pain, lower back pain, painful urination, change in bowel habits, inability to void

Bladder Cancer Diagnosis

• Cystoscopy with biopsy
• Urinalysis (showing blood)
• Urine culture (for infection detection)
• Urine Tumor Markers & Imaging tests

Bladder Cancer Treatment

• Chemo
• Bacillus Calmette Guerin (BCG) therapy in bladder to trigger immune system to attack cancer cells also an option
• Photodynamic therapy
• Ileal conduit- for clients unable to care for a continuant diversion

Kidney Cancer

• Is a top 10 common cancer

Kidney Cancer Etiology

• Ages 65-74
• Higher risk for men
• Smoking, obesity, HTN, long term kidney dialysis, genetics, radiation exposure, and industrial pollution are risk factors

Kidney Cancer Signs and Symptoms

• Hematuria
• Dull pain and flank area
• Mass in area
• Fever, weight loss, night sweats, HTN, anemia, polycythemia, swelling in legs, fatigue, anorexia, constipation, and less specific

Kidney Cancer Diagnosis

• Cystoscopy
• Pyelogram
• Ultrasound exam of kidneys
• CT scan of abdomen
• MRI
• Renal biopsy (definitive diagnosis)

Kidney Cancer Treatment

• Radical nephrectomy removes entire kidney along adrenal gland
• Radiation and chemo
• Immunotherapy

Chronic Renal Disorders

• Diabetic nephropathy: diabetes is most common cause of Chronic Kidney Disease (CKD) from elevated glucose levels

Diabetic Nephropathy Risk Factors

• Chronic hyperglycemia
• HTN
• High cholesterol
• Genetics
• Smoking

Diabetic Nephropathy Patho

• Hyperglycemia leads to increased diuresis and increased GFR
• Atherosclerotic changes reduce blood supply to kidneys
• Abnormal thickening of glomerular capillaries, causing damage
• Protein enters urine, causing renal scarring
• Urine retention, risk of infection, kidney damage
• Nephrotic syndrome & massive edema due to low albumin are possible

Diabetic Nephropathy Signs and Symptoms

• Persistent elevated albuminuria
• Proteinuria
• HTN
• GFR decreases
• Accumulation of waste

Diabetic Nephropathy Complications

• Risk for cardiovascular disease

Diabetic Nephropathy Diagnostics

• Albuminuria or protein spillage monitoring
• Kidney biopsy

Diabetic Nephropathy Treatment

• Keep A1C less than 7%
• ACE inhibitors and ARBs used for HTN
• Statins used for cholesterol
• Dialysis or kidney transplant

Nephrotic Syndrome

• Excretion of 3.5 grams or more of protein in urine per day
  • Decreased total serum protein and serum albumin
  • Fluid shifts from blood vessels into tissues causing ascites/widespread edema
  • Foamy urine from lipoproteinemia is present
  • Immunocompromise, protein imbalance, and increased blood coagulation are complications
• ACE inhibitors, ARBs, loop diuretics, sodium restriction to 2g/day, statins, and anticoagulants are used treatment

Nephrosclerosis

• Related to hypertension that causes sclerotic changes
  • Ischemia of kidneys leads to kidney damage
  • Increased glomerular pressure and filtration
  • High BP causes vessels weaken and hemorrhage
  • Proteinuria, hyaline casts in urine, CKD are signs and symptoms
• Treatment- antihypertensives, low sodium diet, dialysis
• Top priority nursing diagnosis- Ineffective Health Maintenance Behaviors (to help manage hypertension)

Glomerulonephritis

• Inflammatory disease of filtering unit of kidney (glomerulus)
  • Immune reaction causes glomerulus to be porous, resulting in protein, WBCs, and RBCs leakage into urine

Glomerulonephritis Etiology

• Acute poststreptococcal glomerulonephritis- group A beta strep
• Goodpasture syndrome- autoimmune response
• Chronic glomerulonephritis

Glomerulonephritis Signs and Symptoms

• Hematuria
• Proteinuria
• Electrolyte imbalances
• Renal insufficiency
• Edema
• Hypertension
• Thrombotic events
• Edema around eyes and face (periorbital edema)
• Ascites (edema around abdomen)
• Pleural effusion (edema in lungs)
• Flank pain

Glomerulonephritis Complications

• Acute renal injury
• Chronic glomerulonephritis

Glomerulonephritis Diagnostics

• Urinalysis shows protein, casts, and RBCs
• Dark and cola-colored urine from RBCs
• Foamy urine from proteinuria
• Elevated BUN and creatinine

Glomerulonephritis Treatment

• Control edema
• Restrict protein Acute Kidney Injury (AKI)
• Kidneys cannot clear waste products, causing rapid accumulation of toxic wastes, or azotemia

AKI Patho

• 3 mechanisms: hypoperfusion, direct tissue injury, hypersensitivity
  • Initiating phase
  • Oliguric phase
  • Diuretic phase
  • Recovery phase

AKI Etiology

• Prerenal injury: before kidney injury; most common cause; hypotension (dehydration, surgery, blood loss, shock, blockage, use of NSAIDs and COX inhibitors)
• Intrarenal injury: inside kidney injury; ischemia, toxins, reduced blood flow, glomerulonephritis, trauma, or exposure to nephrotoxins
• Postrenal injury: after kidney injury; urine cannot drain out of kidney resulting in impaired nephron function; kidney stones, tumors of ureters or bladders, enlarged prostate

AKI Treatment

• Fluids
• Discontinue nephrotoxic drugs
• Bypass obstructions
• Short-term renal replacement therapy
• Continuous renal replacement therapy (CRRT)

Chronic Kidney Disease (CKD)

• Is the 8th leading cause of death in the U.S.

CKD Patho

• Renal insufficiency stage: when there is 75% loss of nephron function
  • May cause anemia and inability to concentrate urine
  • End stage renal disease: when there is 90% loss of nephron function
  • Makes urine but cannot filter waste products
  • May become anuric and produce no urine

CKD Etiology

• Diabetes mellitus
• Chronic hypertension
• Glomerulonephritis

CKD Signs and Symptoms

• Oral cavity- stomatitis, bad taste
• Cardiovascular: hypertension, HF, arrhythmias
• Gastrointestinal: anorexia, N/V, GI bleeding, ulcers
• Reproductive: sexual dysfunction, infertility
• Musculoskeletal: prone to fractures
• Neuro: fatigue, depression, headache, confusion, seizures, coma
• Respiratory: pulmonary edema or effusion, dyspnea
• Integumentary: pruritis, ecchymosis, uremic frost, dry skin, yellow skin
• Renal: anemia, oliguria or anuria
• Fluid volume- edema

CKD Electrolyte Imbalances

• Electrolyte imbalances: Edema (early symptom)- seen in extremities/abdomen/sacrum
• Shortness of Breath (SOB)
• Crackles and wheezing
• Hypertension
• Polyuria, oliguria, or anuria
• Hypernatremia- causes water retention, edema, HTN
• Hyponatremia- causes confusion; due to diarrhea or vomiting
• Hyperkalemia- LIFE THREATENING if above 6.5 mEq/L; causes cardiac arrest, arrhythmias, muscle weakness, and abdominal cramps or diarrhea
  • Cardiac monitoring is important
• Avoid potassium foods- lentils, avocado, banana, melons, cheese/milk/yogurt, prunes/raisins, nuts, potatoes/spinach
• Hemodialysis is the main treatment
• Glucose (rapid potassium shifter) Causes cells to take in potassium Use Kayexalate for maintenance Hypocalcemia and hyperphosphatemia can occur, posing a risk foe fractures

CKD Disturbance of Removal of Waste Products

• Causes azotemia- weakness, fatigue, confusion, seizures, twitching, N/V, lack of appetite
  • Hemodialysis is the only treatment option
  • Metabolic taste in mouth
  • Yellowish skin and itching

CKD Acid-Base Balance

• Causes metabolic acidosis- headache, fatigue, weakness, nausea, vomiting, lack of appetite
  • Progression causes lethargy, stupor, coma
  • Deep and rapid respirations (to blow off CO2)- “Kussmaul breathing”

CKD Hematologic Function Disturbance

• Not enough erythropoietin (no stimulation for RBC production)
  • Epoetin (synthetic form) is given to help RBC production and prevent anemia

CKD Therapeutic Measures

• Diet- low protein and fluid restriction
• Medications- diuretics, ACE inhibitors, ARBS, CCBs, BBs
• Hemodialysis- use of artificial kidney to remove waste and excess fluid
• Peritoneal dialysis- continuous dialysis performed by patient or family

Female Reproductive System: 

• Ovaries: a pair of oval structures on either side of the uterus in the pelvic cavity
  • Eggs cells are created by oogenesis (meiosis)
• Begins in the fetus
• Pauses
• Resumes at puberty then ends at menopause
• One mature sperm with its 23 chromosomes is produced and released roughly every 28 days by hormonal control
• Ovarian follicles form to make and secrete estrogen & progesterone during menstruation
• Fallopian Tubes carry from the ovaries to the uterus
  • Fimbiae draw an ovum into the tube with ciliated epithelium transporting towards the uterus
• Uterus: The curved upper portion is the fundus: the 2 upper corners connect to the fallopian tubes
• Pregnancy causes uterus volume increases. Houses and creates part of the placenta to nourish of the fetus until delivery. Rising Levels of oxytocin hormone increases which increases uterine contractions.
  • The uterus has 3 primary layers: External perimetrium, Myometrium, Internal Endometrium:
  • Endometrium: inner lining that is most vital for tissue protection of a highly vascular mucous membrane. The endometrium tissue is crucial because a portion is lost and regenerated with each menstrual cycle.
  • Pregnancy: the Endometrium helps support forming the outer layer maternal side of the placenta.
• Vagina: extending from the end of the uterine cervix and or vaginal opening
• After the start of puberty the vaginal openings after develop the support against infection. Bacteria is present with good ph balance in the area that creates a acidic ph.
• Mammary Glands: Adipose tissue that are enclosed within the breast.
  • Produce milk to make milk after pregnancy.
  • Hormonal influence that can increase levels of progesterone and create lactation during pregnancy. Prolactin: increases Milk and creates during pregnancy
• Breast feeding: Can stimulate levels of contractions which stimulates milk release.

Male Reproductive System: 

• Testes: Needs support to produce for viable sperm to be produced. Once the production of puberty has occurred, it's constant rather then a continual production process through life. Levels of LH contribute and maintain the production sperm and increase testosterone.
  • Seminal Vesicles, Prostate Gland and Bulbourethral Glands: bilateral seminal vesicles, Bulbourethral glands and Singular prostate that are active in the MALE reproductive pathway

Aging & Reproductive Systems:

• Menopause: ends the definite stage of the reproductive system
  • Occurs for well over 12 months or longer
  • Normally occurs in the age bracket of 45-55 for females
• Male:Most men continue to maintain testosterone at a standard rate that's equivalent to males who do maintain sperm production.
  • Most common of male system is an enlarged prostate during elder care.

Female Reproductive System Assessment: 

• Knowing baseline functions is important for the reproductive and sexual performance in the system to maintain and take care in the collection to take the best prep for collection. Is defined as PAIN FREE throughout puberty
• Educate on regular intercourse activity.
• The time period is expected every around 40 weeks for pregnancy.
• Take accurate health record on pregnancy and any medical conditions.
• Reassure and create a safe space for patients to discuss feelings and concerns.

Clinical Assessment:

• Palpation: Most important part of a breast examination to confirm the presence of lumps and to locate areas of tenderness.
• Mammograms are not always sensitive enough to detect a small percentage of masses compared to what we can examine by palpation.

Common Benign Breast Disorders:

• Cyclic Breast Discomfort:
  • Causes: The breast tissues are sensitive to hormone. Changes in hormones can cause sensitivity that leads to pain.
• Mastalgia*( breast pain ): Pain can correlate or maintain within the breast tissue to prepare the breast for its role in breastfeeding.
• Treatment*:persistent irritation, inflammation and pain can be reduce hormone production, and be treated with NSAIDS to control pain.**
• Fibrocystic*: Caused in part by hormone changes, the cells develop fibrous tissue within the breast.
  • Common in women between ages 30-50
  • Fibrocystic changes reduce pain with menopause
  • Identified on palpation and found with an ultrasound.
• Treatment*: depends on the presenting symptoms
• Mastitis*(breast inflammation/infection)
  • S/S:* Breast is red and very painful
  • Abscesses in the breast.
  • Treatment*: antibiotics, incision and draining, NSAIDS, warm packs, and breast support.

Proper Health & Education:

• Educate on proper general hygiene
• Educate to empty/drain the breast

Malignant Breast Disorders:

• Patho & Etiology:
  • Breast or breast milk can arise from the milk production glands and/or the conective tissues of breast.
  • Diagnosed: Increase in weight/age,High risk diets, High intake of alcohol. Family history is also a factor
• S/S:
  • A lump or thickening of tissue can indicate breast cancer.
  • Discoloration, retraction, swelling and tenderness are all signs

Breast Cancer Prevention

• Moderate exercise
• Diet adjustment and limits of alcohol intake
• Reduce breast feeding risk and get genetic testing as needed
• Examination in self and breast is required
• Mammograms with Biopsies

Stages to cancer testing from one to four, each test and stage is measured to diagnose the process, spread, and or the metastasis of cancer in the cells.

• Therapeutic Measures:
  • Radiation therapy - to help attack all rapidly dividing cells with internal or external approaches and reduce the spread
  • Chemotherapy- Kills all rapidly dividing cells which leads to many side effects
  • Hormone therapy - to reduce the production of hormones to impair cancer's spread
  • Immunotherapy - decrease infection, reduce pain and kill cancerous pathogens and viruses
  • Common process with 5 step surgeries - Lumpectomy - removal of a margin. Mastectomy with tissue can take place, depending on the patient more radical treatments are at times Mastectomy tissue will be performed and the patient is checked for a full treatment as desired. Full recovery may be slow and the pain medication should be prescribed.

Menstrual cycle / syndrome PMS / PMDD

• Cause: Recurring or recurring problem for women, the exact is a cause

S/S of PMS/PMDD

• Water retention, headaches, discomfort, changes in sensory, increase depression, irritability, and tension

Treatment

• Measures: Hormonal birth control Increase and help Vitamin intake Weight and health maintenance Decrease coffee, sugar, tobacco, alcohol, salt

Flow Cycle Issues

Stress, hormonal, metabolic problems, abnormal growths, diseases, and bone marrow abnormalities

Diagnosis & Treatment

• Need good relations with healthcare workers in the field
• Pap smears and endometrial tests

Tests and care and education are needed to test and maintain the health and comfort

• Amenorrhea: Menses are completely absent for over 6 months / 3 cycles consecutively.
  • Primary Amenorrhea: has not occur until time of 17/
  • Secondary Amenorrhea: occurs after menarche
• Hypermenorrhea (Menorrhagia): Menses are longer than 7 days

- Dysmenorrhea: Is painful menstruation

Causes or origin: increased amounts of the prostaglandin

• Primary dysmenorrhea is not always pathological and due to activity of endogenous prostoglandins
• Secondary is caused by reproductive tract malfunctions