Chapter 18 Altered Elimination—Urinary System 2023 PDF

Chapter 18 Altered Elimination—Urinary System Overview: Altered urine elimination- 4 types Overview of clinical manifestions, diagnositic tools -Infections (UTI, pyelonephritis) (Review Ch. 5) -Urolithiasis (kidney stones) -Acute Kidney Failure...

Chapter 18 Altered Elimination—Urinary System Overview: Altered urine elimination- 4 types Overview of clinical manifestions, diagnositic tools -Infections (UTI, pyelonephritis) (Review Ch. 5) -Urolithiasis (kidney stones) -Acute Kidney Failure -Chronic Renal (Kidney) Disease -Kidney Failure -Polycystic Kidney Disease -Urinary incontinence -Benign Prostatic Hypertrophy -Misc. cancers of urinary system; and other misc. urinary tract conditions Concept Map: of Altered Elimination What are the general causes of altered elimination?  Altered Urinary Elimination- #1 v Altered motility o Reduced contraction of: § Renal tubules § Ureters v Etiology: cancer, stones, congenital v What are complications of decreased motility? o Stasis of filtrate in tubules, urine in bladder -à o Casts (collection of renal cells) may form: risk of obstruction o Leads to altered reabsorption and secretion Altered Urinary Elimination #2 § Altered Neuromuscular Function Dysfunction of the bladder Etiology: nervous system injury Who is at risk for neurogenic bladder?__________________ Symptoms may include: Decrease sense of need to void -àincontinence Inability to fully empty bladder—>retention Treatment goals: preventing UTIs and controlling incontinence. Treatment: Catheterization  Altered Urinary Elimination #3 vAltered perfusion o Inadequate blood supply to kidney Etiology? When could this happen? _____________________ vComplications o Ischemia and/or inf______ (area of dead tissue caused by the ischemia) o Pain o Altered reabsorption and excretion o Renal failure Altered Urinary Elimination #4 vAltered patency of ureters, urinary pelvis, etc. o Etiology: obstruction—like stones vComplications o B_______.of urine flow o Dilation of structures pro________ to obstruction o Stasis ________ of urine, leading to infection o **Injury to renal anatomy General Clinical Manifestations of Altered Urinary Elimination vAltered volume of excretion: vAnorexia vPolyuria______ vNausea, Vomiting, Fever vOliguria_____ vAnuria______ vFrequency vUrgency vDysuria _______ vAltered excretion characteristics: hematuria_____ pyuria_____ proteinuria_______ General Diagnostic Tests for Kidney Function vIntravenous pyelogram (IVP) vCystogram (cysto=bladder) vCystoscopy vBladder and kidney biopsy vRenal ultrasound, CT scan vUrine tests : urinalysis vBlood tests GFR (glomerular filtration rate) – Serum Creatinine – BUN (blood urea nitrogen) – Serum urea – General urinary tests vMacroscopic urine (visual inspection) o Evaluate color and clarity vUrine dipstick o pH, specific gravity, protein, glucose, ketones, nitrite (infection), leukocyte esterase, blood vMicroscopic urine evaluation o Look for crystals, casts, squamous cells, white and red blood cells, bacteria  Urinary Catheterization-use of a flexible tube to drain or collect urine When do we use catheterization? ______________ Which is most at risk of leading to infection? ________ Types: Stays in. In-and-out External. Purewick catheter “Straight cath” = using intermittent catheter to draw out a sample or drain bladder Clinical Example: Urolithiasis (Kidney Stones) Pathophysiology vDevelopment of renal calculi (kidney stones) anywhere in the renal system: These are solid masses precipitated from filtrate vWhat causes kidney stones? o Urinary stasis o Elevated urinary levels of salts, organic or inorganic acids: (examples: calcium, uric acid) vRisk of renal tubule obstruction  Urolithiasis Clinical Manifestations vPain!!! o Renal colic pain—occurs when stone is _____________________ Acute, intermittent, radiating, excruciating “worse than childbirth” o Non-colic pain § Distention of renal calices or pelvis § Dull, deep with varying intensity Urolithiasis Diagnostic Criteria v Subjective findings o History of pain (lower back) o Pain can radiate to groin o Pain with urination, urgency, Hematuria, F/C/N/V_______________ v Imaging studies: o CT scan or IVP (intravenous pyelogram) or KUB ____________________ X-ray v Laboratory analyses o Lab: Urinalysis o Lab Analysis of calculi (stone) composition Urolithiasis Treatment vSupportive treatment o Pharmacologic: Pain control o Increased fluid intake to help passing stone— strain urine to catch stone for analysis o Lithotripsy (ultrasound waves) breakup stones o Surgical: calculi removal  Who’s more at risk for developing kidney stones? Prevent recurrence: Hydration Diet with foods low in calcium oxalate Clinical Example: Renal Failure Failure of kidneys to cleanse blood of waste products like urea. Urea is converted to ammonia and can be toxic to the brain Can be acute (and recover) or chronic Symptoms might include: decreased urine output fluid retention (edema), shortness of breath, fatigue, confusion, nausea, weakness, irregular heartbeat. Acute Renal Injury/Failure Bb video: https://www.youtube.com/watch?v=xcrfhVYJ0kM § Can be caused by sudden decreased blood supply to kidneys. So…perfusion is ________ § Etiology: hemorrhagic or surgical shock, embolism, CHF, severe dehydration, certain medications, sepsis. Sudden drop in BP. § Can be reversible. Complications: qAccumulation of urea qFluid imbalance (hypervolemia) qElectrolyte imbalance (hyperkalemia) qAcid-base imbalance (can’t excrete H+) Chronic Kidney Disease Slow onset, progressive GFR used to categorize Causes: often part of a chronic kidney disease process like diabetes, hypertension, or glomerulonephritis. -Video: https://www.youtube.com/watch?v=fv53QZRk4hs Pathophysiology of Hypertension Impact on Kidney: causes thickening of blood vessels to glomerulus--à decreases lumen size -à decreased blood and oxygen to the kidney Chronic Kidney Disease (CKD) Progressive Disease: 5 Stages The disease is classified based on estimated GFR and other kidney markers Dialysis starts Chronic Kidney Disease—Pathophysiology SUMMARY Functions of the kidney Manifestations of decreased renal function/failure Complications Osteoporosis  Clinical Manifestations of Kidney Failure Related to Kidney Functions! Not significant until 75% of kidney function destroyed Edema Infertility / impotence Bone weakness / fractures Anemia Hypertension Bleeding Acidosis Diagnosis – Blood tests: GFR, creatinine & BUN levels Treatment: ?___________________ (next slide) Long-term treatment of Kidney Failure- 1) Dialysis – procedure that cleanses the blood of waste products Peritoneal (done at home) Hemodialysis (in clinic) When does dialysis start? Kidney function________ eGFR_________________ 2) Transplant Hemodialysis vHemodialysis during end-stage renal disease Vascular access is required for dialysis 2. AV graft used if AV fistula isn’t an option. More prone to clot 1. Preferred access. WHY? 3. Central Venous Catheter Access  Clinical Example: Polycystic Kidney Disease (PKD) vEtiology: Genetic condition(one type is autosomal dominant and another is recessive) vPathophysiology: § growth of fluid-filled cysts in kidneys § Functional tissue replaced Clinical manifestations: § Reduced perfusion § Tubule obstruction § How would this condition impact kidney function and GFR? Treatment: treat complications like infections; pain meds;hypertension; may need dialysis eventually  Clinical Example: Urinary Incontinence § Inability to voluntarily prevent the discharge of urine § Who is at risk of developing incontinence? § Why? § Can certain medications make this condition worse? vEnuresis § term used mostly for nighttime bedwetting in children vUrinary incontinence: VERY common issue v Etiology: - changes in nervous system control (age, or disease, post stroke, etc) - decrease in muscle tone due to a decrease in estrogen level - decrease in abdominal muscle tone (multiple pregnancies or obesity) v Types -Overflow: Causes leakage -Stress: Coughing/sneeze/laugh , -Urge: need to go quickly: infection, neurological -Functional: unable to toilet independently Urinary Incontinence Diagnosis H&P Urodynamic studies: Cystometry : test that studies the filling and emptying of the bladder Post-void residual tests: checks how much urine is left in bladder after patient voids (ultrasound) Urinary Incontinence Treatment: Behavioral techniques, such as------ Double voiding___________ Schedule ______________ Bladder training___________ Kegel exercises? What are Kegels and what’s the purpose? Other Treatments: -Estrogen creams: strengthen urethral sphincter -Collagen injections near external sphincter to narrow urethra opening -Medications to calm overactive bladder -Many surgical options (“sling procedure” to lift bladder)  Clinical Example: Interstitial Cystitis § Nonbacterial cystitis due to inflammation of inner lining of bladder. § May be autoimmune. § Pelvic pain § Urinary frequency § Affects mostly young women § Treatment: q Medications like pain meds, antidepressants, bladder protecting meds q Pelvic floor PT q Bladder training q Nutrition adjustments can help (low acid) Clinical Example: Benign prostatic hyperplasia (BPH) “Benign” enlargement of prostate gland due to normal cell overgrowth and enlargement 50% of males age > 50 have prostate enlargement. Diagnosis: digital rectal exam (DRE) __________ Monitoring PSA blood level (prostate specific antigen). May need biopsy Symptoms: due to pressure on the bladder & urethra: qNocturia and Frequency qHesitancy: inability to start urination and weak urinary stream qInability to empty bladder; can lead to excess urine in ureters (hydroureter, hydronephrosis, and UTIs) Treatment for BPH Where are alpha receptors? _______________ Respond to which NT? _______ Treatments for symptoms: medications like alpha-blockers (Flomax) that relax bladder muscles and improve urinary flow Surgery is another treatment: Transurethral Resection (TURP)— surgeon removes excess prostate tissue that is pushing on the bladder  Prostate Cancer § SLOW GROWING Neoplasm of prostate gland affecting males > age 50. 2nd most common cause of male cancer-related deaths § Symptoms: qOften asymptomatic until metastasizes qIf symptomatic they are similar to BPH § Diagnosis qincludes DRE (digital rectal exam)—hard and enlarge prostate. qmonitor blood level of PSA (prostate surface antigen) qbiopsy: definitive test § Treatment Options: qSurgery (prostatectomy). qHormone therapy to slow growth qWatch and wait. Slow growing, so often older individuals die of other causes Kidney Cancer: Adenocarcinoma § Risk factor: Cigarette smoking § Frequently metastasizes to liver, brain, and bone before symptoms appear § Symptoms: qPainless hematuria qFlank pain qFever Diagnosis by KUB, IVP, CT scan, and biopsy Treatment: nephrectomy Bladder Cancer vCarcinoma of the bladder § Arises from lining of bladder § Often metastasizes before symptoms Risk factors: cigarette smoking, chemical exposure, chronic cystitis, more common in men>60 Clinical Manifestations: hematuria, dysuria, nocturia Diagnosis: cystoscopy and biopsy Treatment qTransurethral resection (TUR): remove tumor qRadical cystectomy: remove bladder qRadiation and chemo if metastasis