What is “spaghetti?”

“Spaghetti” is unnecessary and unrelated to the meatballs! Your statements should be objective. They are not narrative. Do not add strings of thought (i.e., the

“spaghetti”) that are not directly related to your pertinent statement.

To be a meaningful contribution to the patient’s care, the statement must be concise, clear, and….“meaty.”

3

Physiological basis of the care of the elderly client

The Genitourinary and Renal Systems

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D.K. is an 88 year old female who lives at home independently

Her son brings her in stating she is increasingly disagreeable, suspicious, and she refuses to eat

VS: T 99.6 P 98 RR 22 BP 112/64 Normally fastidious, she is unkempt She complains of nausea and that she

cannot control her urine

Patient Scenario

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What additional information do you need?

Subjective information Objective information Psychosocial information

Informal evaluation

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WBC in CBC is 15,000 Urine culture shows 120,000 bacteria CFU

(colony forming units)

Additional information for DK

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Anatomy of the nephron

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Location of the kidney

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Relative size of the kidney

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Renal xray

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Removal of waste Fluid and electrolyte balance Acid-base balance Blood pressure Red blood cell production

Functions of the kidney

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Conserve: water is concentrated

compared to plasma

Rid: water is dilute relative to

plasma

How kidneys influence fluid and electrolyte balance

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Vasopressin (ADH) secreted by the hypothalamus

Increases water permeability in the cell membranes lining the water channels of the kidneys’ collecting duct

Allows water reabsorption

How kidneys control water excretion

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Urine specific gravity

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Regulation of osmolarity (amount of solute per unit of volume)

Sodium is major solute in extracellular fluid Aldosterone is secreted by renal cortex in

response to changes in osmolarity Aldosterone promote reabsorption of sodium in the distal nephron

How kidneys influence sodium balance

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Reabsorption of bicarbonate filtered at the glomerulus

Work in compensatory mode with lungs

How kidneys maintain acid-base balance

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↓ in BP & filtered Na

Kidneys release renin

Renin converts angiotensinogen → angiotensin I

ACE converts angiotensin I

into angiotensin II

Angiotensin II causes vessels

to contract

Vessel contraction causes ↑ BP

How kidneys influence blood pressure

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Kidney secretes erythropoietin Erythropoietin acts on the bone marrow to

increase red blood cell production

Promotes red blood cell survival

How kidneys influence red blood cell production

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Decline begins around age 40 Generally not significant until

age 90+ Decreased number of glomeruli Decreased GFR Decreased renal

blood flow Decreased response

to sodium loss

Normal age related changes

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↑ susceptibility to drug

overdose

↑ probability of

hyperkalemia

↑ propensity to dehydration

↓ fluid intake ↓ response to fluid overload

General consequences of age related changes

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Hypertrophy of the bladder muscle Thickening of the bladder wall Decreased ability of the bladder to expand Reduced storage capacity

Age related changes in bladder and urethra

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Testes become less firm ↓testosterone production → ↓ muscle mass and

facial & body hair Prolonged arousal time, time before climax, and

refractory time

Changes in male reproductive system

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Decreased/absence of ovarian function → perimenopause and menopause

Deceased estrogen levels◦ Less vaginal lubrication◦ ↑ risk of urinary incontinence, infection, retention◦ ↓ body hair, ↑ facial hair

Changes in sexual response

Changes in female reproductive system

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Inability to remove nitrogenous waste from the body

Inability to regulate:◦ Fluid◦ Electrolytes◦ Acid-base balance

Acute = sudden onset, may be reversible Chronic = occurs over time, damage is

irreversible

Renal failure in the older adult

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Consequences of renal failure

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Causes of Acute Renal Failure

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Due to decreased blood supply to kidney Dehydration from loss of body fluid

◦ Vomiting◦ Diarrhea◦ Sweating◦ Fever

Poor intake of fluids Medications, e.g., diuretics Abnormal blood flow to the kidney due to

obstruction

Pre-renal causes of kidney failure

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Direct damage to the kidney itself Sepsis causing inflammation and shutdown Medications

◦ NSAIDs◦ Aminoglycosides◦ Iodine-containing medications

Rhabdomyelosis (damaged skeletal muscle breaks down rapidly, breakdown products can harm the kidney)

Multiple myeloma Acute glomerulonephritis

Intrarenal causes of kidney failure

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Due to factors affecting urine outflow Obstruction of bladder or ureters Prostatic hypertrophy, cancer Tumors of the abdomen Kidney stones

Post-renal causes of kidney failure

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Diabetes Benign prostatic hyperplasia Hypertension Long-term NSAID use

Common causes of chronic renal failure specific to the older adult

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Pruritis Malaise Generalized edema Cognitive changes Anorexia Nausea Weight loss

Common symptoms of chronic renal failure in the older adult

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Adequate fluids Self-awareness when new medications are

started Incontinence is not normal! One’s normal sexual activity level need not change because of advancing age

Teaching points for renal health

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Symptoms of UTI found in younger population may be common in the elderly without UTI such as urgency, frequency

Behavioral or cognitive changes may be the only symptom of UTI

Asymptomatic UTI is not treated Clean-catch urine for culture is indicated in symptomatic UTI

Urinary tract infection

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New urinary urgency Decreased flow initiation time Voiding > 7 times in 24 hours

When to consider UTI

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Urinary frequency, urgency, dysuria Lower abdominal pain, flank pain Mental status changes (confusion!) Sepsis and septic shock Temperature >38◦C/100.4ºF or < 36◦C/96.8ºF Heart rate > 90 bpm Respiratory rate > 20 WBC > 12,000 or < 4,000

Be alert to these symptoms

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“I didn’t want to bother you, Honey!”

“The Problem With A GU Problem”

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Trimethoprim-sulfamethoxazole (Bactrim) has become less effective due to resistance

Fluouroquinolones used instead Nitrofurantoin 100 mg BID Men require longer treatment

Medical treatment of UTI

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Stress—weak pelvic muscles; laughing, sneezing coughing

Urgency—irritation of bladder wall; UTI, BPH, tumor

Overflow—bladder muscles are overextended, retained urine overflows

Types of incontinence (1)

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Neurogenic—inability to sense urge to void; MS, cerebral cortex lesions

Functional—prevented from reaching restroom; dementia, disabilities, sedation, inaccessibility

Types of incontinence (2)

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Drugs Infection Atrophic vaginitis Psychological (depression, delirium,

dementia) Endocrine (hyperglycemia, hypercalcemia) Restricted mobility Stool impaction

Assessing new onset incontinence

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Stress: Kegel exercises, medications, surgery

Urgency: Kegel exercises, medications, toileting schedule

Overflow: toileting schedule, medications, Crede method

Lifestyle modifications:◦ Smoking cessation◦ Weight reduction◦ Bowel management◦ Caffeine reduction◦ Monitoring fluid intake

Treatment of incontinence

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Women: fecal impaction Men: prostatic hypertrophy

Regardless of cause, urinary retention can lead to urinary tract infection!

Common causes of urinary retention

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Obstruction of the vesical neck and compression of the urethra

Hesitancy, decreased stream, frequency, nocturia

May produce dribbling, poor control, overflow incontinence and bleeding

Notes on benign prostatic hyperplasia

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PSA◦ Normal = < nanograms◦ 4-10 nanograms = 25% chance of cancer◦ > 10 nanograms = 50%+ chance of cancer

Cystoscopy Ultrasound Intravenous pyelogram Urodynamic studies

Diagnostics for BPH

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Alpha-adrenergic blocking medications◦ Tamsulosin◦ Doxazosin

Transurethral resections of the prostate (TURP) if renal insufficiency, frequent UTIs, stones, hematuria

Minimally invasive surgery for most cases

Treatment of BPH

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Defined as cessation of menses Early menopause symptoms may include

irregular periods or hot flashes Menopause may include night sweats, sleep

difficulties, and irritability Menopause treatments may include

hormone replacement therapy Herbal remedies for menopause may

include soy foods and supplements Bleeding after menopause is not normal and

likely indicates cancer

Menopause concerns

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History of abnormal Pap smears—annual Pap smears with or without intact cervix

Hysterectomy for previous cancer—annual Pap smears

History of normal Pap smears—annual Pap smears until age 70

Gynecological screening

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Methods are mammography, clinical breast exam, self breast exam

Annual mammography for all women over 40

Breast cancer screening

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Systemic estrogen remains the most effective treatment for relief of symptoms:◦ Hot flashes and night sweats◦ Vaginal dryness, itching, burning◦ Discomfort with intercourse◦ Useful in preventing of the osteoporosis

Low-dose vaginal preparations of estrogen come in cream, tablet or ring form:◦ Can effectively treat vaginal symptoms◦ Can treat some urinary symptoms◦ Do not help with hot flashes, night sweats◦ Do not protect against osteoporosis

Benefits of HRT

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Prempro (combination estrogen-progestin) prescribed before hysterectomy carries increased risk of◦ Heart disease◦ Stroke◦ Blood clots◦ Breast cancer

Premarin (conjugated estrogen) prescribed after hysterectomy◦ No increased risk of breast cancer or heart disease◦ Risks of stroke and blood clots were similar to the combination therapy

Risks of HRT

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Adequate fluid intake Acidic urine (vitamin C, cranberries, plums,

prunes) Activity prevents stasis Frequent toileting Avoid catheterization Regular examinations: annually

or every 6 months if BPH

Further methods of promoting urinary health

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What is your nursing diagnosis for DK?

What is your desired outcome?

What are appropriate interventions pertinent to your desired outcome?

Formal evaluation