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110 Cards in this Set
- Front
- Back
- 3rd side (hint)
Urinary Tract Infections statistics
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-second most common reason to access healthcare
-most common in women - 11.3 mil/yr -most common site of nosocomial infections - 600,000/yr |
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UTIs
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-lower UTIs
-Upper UTIs |
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Lower UTIs
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-cystitis - bladder
-prostatitis - prostate -urethritis - urethra |
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Upper UTIs
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-pyelonephritis - renal pelvis
-renal abscess -interstitial nephritis - kidney -perirenal abscess |
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Risk Factors for UTIs
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-failure to completely empty bladder
-obstructed urinary flow -immunosuppression -instrumentation of urinary tract -inflammation or abrasion of urethral mucosa |
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Obstructed urinary flow
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-congenital abnormalities
-urethral structures -bladder neck contracture -tumors -calculi -compression of ureters -neurologic abnormalities - dysfunctional bladder |
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Clinical Manifestations (UTI)
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-Half of patients are asymptomatic
-Dysuria - painful -Burning -Urgency -Frequency - more than every 3 hours -Nocturia -Incontinence -Suprapubic or pelvic/flank pain |
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Factors Contributing to UTI in Seniors
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-high incidence of chronic illness
-frequent use of antimicrobial agents -presence of infected pressure ulcers -immunocompromise -cognitive impairment -immobility and incomplete emptying -use of bedpan rather than a commode or toilet -Most common presenting symptom is GENERALIZED FATIGUE |
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Diagnosis (UTI)
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-urinalysis
-urine culture and sensitivity -CT Scan/Ultrasound - abscesses or obstructions |
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Medical Management (UTI)
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Acute Pharmacologic Therapy
-Cephalosporins -Aminoglycosides -Sulfas -Fluroquinolones -Urinary analgesics - Pyridium (orange) |
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Nursing Management (UTI)
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Assessment
-History of s/s, voiding pattern, infrequent emptying of bladder, sexual intercourse -Assessment of urine for volume, color, concentration, cloudiness, odor Nursing Diagnoses -Acute pain -Knowledge deficit |
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Nursing Interventions (UTI)
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-Encourage fluid intake (unless contraindicated).
-Report increased pain to physician. -Administer analgesics and antispasmodics for pain and spasm as prescribed. -Provide instructions about recommended voiding patterns and hygienic practices. |
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Patient Education (UTI)
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Hygiene
-Shower rather than bathe -Wipe front to back Fluid intake -Drink lots of water -Avoid coffee, tea, colas, alcohol - urinary tract irritants -cranberry juice, vitamin C Voiding habits -void every 2-3 hours |
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Acute Pyelonephritis
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Signs and Symptoms
-Chills -Fever -Leukocytosis -Bacteriuria and pyuria -Low back pain, flank pain -Nausea & vomiting -headache -malaise -painful urination -frequency -pain and tenderness at costovertebral angle |
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Diagnostic Studies (Acute Pyelonephritis)
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-urinalysis
-urine culture and sensitivity -CT Scan/Ultrasound |
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Medical Management (Acute Pyelonephritis)
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Primarily OP (outpatient)
-antibiotics - 2 weeks -repeat urine C&S 2 weeks after antibiotics finished -hydration |
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Adult Voiding Dysfunction
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-Incontinence - 17 million in US
-Can affect people of all ages - more common in seniors -Risk Factors: age, gender, number of vaginal deliveries |
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Types of Incontinence
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-Stress
-Urge -Reflex -Overflow -Functional -Iatrogenic -Mixed |
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Stress Incontinence
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involuntary loss of urine as result of sneezing, coughing or changing position (decreasing ligament and pelvic floor support)
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Urge Incontinence
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associated with strong urge to void that cannot be suppressed - pt can't reach toilet in time (uninhibited detrusor contraction) (smooth muscle in bladder wall)
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Reflex Incontinence
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due to hyperreflexia in absence of normal sensations usually associated with voiding (spinal cord injury)
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Overflow Incontinence
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Associated with over distention resulting from bladder's inability to empty normally (spinal cord lesions, tumors, strictures, prostatic hyperplasia)
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Functional Incontinence
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lower urinary tract functionally intact but other factors make it difficult for patient to recognize need to void or physical impairments prevent reaching toilet in time (Alzheimer's)
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Iatrogenic Incontinence
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due to extrinsic medical factors, predominantly medications (alpha-adrenergic agents cause bladder neck relaxation to point of incontinence with minimal intra-abdominal pressure)
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Mixed Incontinence
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Combination of different incontinences
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Incontinence Assessment/Medical Management
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Assessment - history, urodynamic testing
Medical management -Behavioral therapy - Kegel exercises, prompted voiding, voiding diary -Pharmacologic - anticholinergics, tricyclic antidepressants, pseudoephedrine, hormone therapy -Surgical management- lifting and stabilizing bladder or urethra, periurethral bulking, artificial urinary sphincter, TURP |
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Nursing Management (Incontinence)
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Patient Education
-Fluid management -Timed voiding, prompted voiding, habit retraining, bladder retraining -Kegel or vaginal cone retention exercises -Transvaginal or transrectal electrical stimulation - re-educates muscles to elicit a passive contraction -Neuromodulation - inhibits detrusor over-stimulation |
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Urinary Retention
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Results from:
-diabetes -prostatic enlargement -urethral pathology (infection, tumor, calculus) -trauma -pregnancy -neurologic disorder - stroke, spinal cord injury, MS, Parkinson's -Medications - anticholinergics, antispasmodic agents, tricyclic antidepressants, beta adrenergic blockers, estrogen |
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Retention Assessment Guide
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-time of last voiding - volume voided?
-Voiding small amounts frequently? -Dribbling urine? -Complaint of pain or discomfort in lower abdomen? -Is pelvis rounded and swollen -Does percussion elicit dullness? -Are other indicators present such as restlessness and agitation? -Does post void bladder ultrasound test reveal residual urine? |
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Nursing Measures to Encourage Normal Voiding
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-Provide privacy
-Ensure environment and position conductive to voiding -Assist to BR rather than BSC or bedpan -Apply warmth to relax sphincters -Turn on water -Stroking the abdomen or inner thighs -dipping pt's hands in warm water -pouring warm water over pubic area |
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Neurogenic Bladder
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-Caused by neuro lesion, spinal cord injury, spinal tumor, herniated vertebral disk, MS, spina bifida or myelomeningocele, infection or DM
Two types: -Spastic or Reflex -Flaccid |
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Spastic or Reflex (Neurogenic Bladder)
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lesion above voiding reflex - loss of conscious sensation and cerebral motor control. Empties on reflex with minimal or no controlling influence
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Flaccid (Neurogenic Bladder)
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lower motor neuron lesion resulting from trauma. Bladder continues to fill and distend and have overflow incontinence. Pt. feels no bladder discomfort
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Medical Management (Neurogenic Bladder)
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-continuous, intermittent or self catheterization or condom caths
-Diet low in calcium to prevent calculi -Encourage mobility and ambulation -liberal fluid intake to reduce stasis and concentration of calcium in urine -Bladder re-training - timed, schedule, double voiding -Parasympathomimetic - Urecholine |
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Renal Calculi statistics
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-renal calculi account for more than 320,000 hospital admissions per year
-Occurs primarily in 3rd to 5th decade -Affects men more than women |
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Pathophysiology (Renal Calculi)
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-formed when concentrations of calcium oxalate, calcium phosphate, and uric acid increase (super saturation)
-Found in both kidney and bladder and vary in size from granules to as large as an orange |
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Factors Favoring Stone Formation
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-infection
-urinary stasis -immobility -increased calcium concentrations in blood and urine (75% stones - calcium) -hyperparathyroidism -renal tubular acidosis -cancers -granulomatous diseases -excessive intake of Vitamin D, milk and alkali -Myeloproliferative diseases - leukemia, multiple myeloma |
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Manifestations of Renal Calculi
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-S/S dependent on presence of obstruction, infection, and edema
-renal pelvis -stone lodged in ureter - ureteral colic -Pt can pass stone 0.5-1 cm. Larger stones have to be fragmented or removed -Stones lodged in bladder |
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Renal Pelvis
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intense, deep ache in costovertebral region and radiating down, hematuria, pyuria, n&v
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Stone lodged in ureter (ureteral colic)
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excruciating, colicky, wavelike pain, radiating down the thigh to genitalia, desire to void. May have hematuria
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Stones lodged in bladder
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symptoms of irritation like UTI and hematuria
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Diagnostics (Renal Calculi)
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Stones confirmed by:
-xrays -ultrasound -IVP -IV urography or retrograde pyelography -blood chemistries -24 hr. urine for calcium -uric acid -creatinine -sodium -pH -total volume |
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Medical Management (Renal Calculi)
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-Opioid analgesics to prevent shock and syncope from excruciating pain
Nutritional therapy: -Calcium stones - increased fluid intake - only restrict Ca with type IIK absorptive hypercalciuria (1/2 of pt) - Thiazide Diuretic -Uric acid stones - low purine diet - Allopurinol -Cystine stones - Low protein diet - Captopril (Capoten) -Oxalate stones - limit oxalate - spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran - Allopurinol & Vit. B6 |
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Medical Management (Renal Calculi)
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Interventional Procedures
-Ureteroscopy: visualizing stone & destroying it with laser, electrohydraulic lithotriptor or ultrasound and placing stent -Extracorporeal shock wave lithotripsy (ESWL) - break stones in calyx of kidney -Percutaneous nephrolithotomy - nephroscope inserted percutaneously into renal parenchyma and stone extracted with forceps or ultrasound probe used to pulverize stone Chemolysis- stone dissolution with chemicals (alkylating agents, acidifying agents) |
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Nursing Management (Renal Calculi)
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-Pain relief - opioids
-Monitoring: -fluid intake -strain all urine -signs of infection -frequent vital signs -patient education: fluid and dietary intake, how to strain urine, signs of infection |
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Bladder Cancer statistics
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-most common in 50-70 y/o
-more men than women -more in Caucasians than African Americans -4th leading cause of cancer in men - 13,000 deaths annually |
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Risk Factors (Bladder Cancer)
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-cigarette smoking
-exposure to environmental carcinogens (dyes, rubber, leather, ink, or paint) -recurrent or chronic bacterial infection of urinary tract -bladder stones -high urinary pH -high cholesterol intake -pelvic radiation therapy -cancer of prostate, colon, and rectum in males |
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Treatment (Bladder Cancer)
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Dependent on grade and stage and multicentricity, pt age and physical status
-Surgical: Transurethral resection followed by intravesical admin. of BCG, Cystectomy-simple or radical -Pharmacologic: Chemo- methotrexate, 5-FU, vinblastine, doxorubicin and cisplatin -Radiation therapy |
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Urinary Diversions
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Urine diverted from bladder to new exit site.
-Ileal Conduit -Cutaneous ureterostomy -vesicostomy -Nephrostomy |
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Ileal Conduit
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ureter implanted into ileal segment and then to surface
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Vesicostomy
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bladder sutured to abd. wall and creates stoma for drainage
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Nephrostomy
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catheter inserted into renal pelvis
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Continent Urinary Diversions
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-Indiana
-Kock pouch -Modified Kock -Ureterosigmoidostomy |
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Indiana
(Continent Urinary Diversions) |
-ureters attached to segment of ileum and cecum. Stoma catheterized
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Kock pouch
(Continent Urinary Diversions) |
-ureters connected to small bowel and develops continence mech/valve. Stoma catheterized
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Modified Kock
(Continent Urinary Diversions) |
-attach 1 end of pouch to urethra in males only for more normal voiding
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Ureterosigmoidostomy
(Continent Urinary Diversions) |
-ureters connected to sigmoid colon and through rectum
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Benign Prostatic Hypertrophy/Hyperplasia (BPH) statistics
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-Half of men 50 y/o and 80% of those 80 y/o
-BPH is responsible for 375,000 hospital stays/year -African Americans develop BPH at a younger age (40) |
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Risk Factors (BPH)
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-smoking
-heavy alcohol consumption -hypertension -heart disease -diabetes Hypertrophied lobes of the prostate obstruct the vesical neck causing incomplete emptying of the bladder and urinary retention. Estradiol may have an effect. |
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Manifestations (BPH)
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-frequency
-nocturia -urgency -hesitancy -abdominal straining with urination -decrease in volume and force -interruption of urinary stream -dribbling -sensation of incomplete emptying -retention -recurrent UTIs -azotemia: concentration of urea and other nitrogenous wastes in the blood -renal failure can occur |
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Treatment (BPH)
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If pt presents ot ER with inability to void - catheterize - may need stylet
Pharmacological -Alpha-adrenergic blockers (Hytrin, Cardura, Flomax): relax smooth muscle of bladder neck and prostate -Antiandrogen agents (Proscar, Avodart) -Saw palmetto: herbal product Surgical -Transurethral Incision of Prostate (TUIP) -Transurethral Prostatectomy (TURP) -Transurethral needle abalation -Microwave thermotherapy |
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Nursing Management (BPH)
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Post TURP
-Usual postop monitoring -Monitor for excessive bleeding -Force fluids unless contraindicated -May have continuous bladder irrigations -Catheter until bleeding has stopped -May have difficulty voiding after cath removed |
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Prostate Cancer statistics
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-Most common cancer in men other than nonmelanoma skin cancer - highest in African American men
-2nd most common cause of cancer death in men (lung CA first) -Survival rate - 98% at 5 yrs, 84% at 10 yrs, 56% 15 yrs -Rare in Asia, Africa, Central/South America -Incidence increases after 50 y/o and in men who have high dietary intake of red meat and fat |
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Clinical manifestations (Prostate Cancer)
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-Difficulty and frequency of urination
-Retention -Decreased in size and force of stream -Hematuria -Back, hip perineal pain from metastasis -Anemia -Weight Loss -Weakness -Nausea -Oliguria |
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Diagnosis (Prostate Cancer)
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-Digital rectal exam
-Prostate specific antigen (PSA) -ACS recommends every man 50 y/o and older have annual rectal exam and PSA -Bone scans |
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Treatment (Prostate Cancer)
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-Surgical
---radical prostatectomy ---cryosurgery -Radiation ---teletherapy - external beam radiation tx ---Intensity-modulated radiation therapy (IMRT) ---Brachytherapy - implantation of interstitial radioactive seeds -Hormonal therapy ---Orchiectomy - removal of testes (testosterone) ---Nonsteroidal antiandrogen bicalutamide (Casodex) and/or DES - diethylstilbesterol to inhibit response to androgenic activity -Chemotherapy |
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Nursing Management (Prostate Cancer)
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-Routine postoperative care
-Monitor postop complications ---hemorrhage ---infection ---deep vein thrombosis ---obstructed catheter ---complications with catheter removal ---sexual dysfunction -Patient education ---Management of cath at home ---wound care ---S/S to report ---perineal exercises |
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Acute Renal Failure (ARF)
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-Reversible syndrome with sudden and almost complete loss of kidney function over period of hours to days.
-Increase in serum creatinine and BUN May have: -oliguria -nonoliguria -anuria -Mortality rate 60-80% |
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Oliguria
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Urine less than 400 cc/day
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Nonoliguria
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Urine greater than 400 cc/day
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Anuria
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Urine less than 50 cc/day
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Categories of ARF
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-Prerenal
-Intrarenal -Postrenal |
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Prerenal
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-(60-70%) - impaired blood flow to kidney and decreased GFR
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Intrarenal
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-Parenchymal damage to glomeruli or kidney tubules (ATN) usually from nephrotoxic agents (aminoglycosides, radiocontrast agents = 30%)
-Burns, crushing injuries, infections, transfusion reactions |
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Postrenal
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Obstruction distal to kidney
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Phases of ARF
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-Initiation
-Oliguria -Diuresis -Recovery |
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Initiation
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-begins with insult; ends when oliguria develops
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Oliguria
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-increase in serum concentration of substances excreted by kidneys. Uremic symptoms first appear and hyperkalemia develops
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Diuresis
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-gradual increase in output; labs stop increasing; uremic symptoms may still exist
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Recovery
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-improvement of renal function - may take 3-12 months
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Manifestations of ARF
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SEE Table 44-2 in textbook
etiology- Prerenal- hypoperfusion Intrerenal- parenchymal damage Postrenal- Obstruction |
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Diagnosis (ARF)
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-low specific gravity of urine - inability to concentrate urine
-Ultrasound - anatomical changes in kidney -Increase BUN - rate dependent on degree of catabolism -Increased creatinine - indicates glomerular damage -Hyperkalemia -Metabolic acidosis -Decrease in serum pH -Anemia - reduced erythropoietin production |
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Prevention of ARF
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-Provide adequate hydration
-Prevent/treat shock promptly -Monitor CVP and arterial pressures and hourly I&O of critically ill pts -Treat hypotension promptly -Continually assess renal function -Ensure appropriate blood administration to pts -Prevent & treat infections promptly -Pay attention to wounds, burns and other precursors of sepsis -meticulous cath care and d/c caths asap -Closely monitor medications excreted by kidney |
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Medical Management (ARF)
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-Maintaining fluid balance
-treat underlying cause immediately -If hypovolemia due to hypoproteinemia - administer Albumin -Dialysis -Pharmacologic ---Hyperkalemia - Kayexalate ---Reduce medication dosages ---Diuretics ---Other agents to treat symptomatology -Nutrition ---Weigh daily to determine nutritional deficiencies and correct |
if hypovolemia due to hyoproteinemia - give Albumin
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Nursing Management (ARF)
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-Monitor fluid and electrolyte balance
---I&O ---Labs ---EKG patterns ---IVs in smallest volume possible -Bedrest to decrease metabolic rate -Turn, cough, deep breathe -Prevent infection - strict asepsis with cath, lines, wounds, etc. -Skin care - dry, excoriated, itchy (uremic frost) -Provide support - life threatening - may require dialysis |
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Chronic Renal Failure (ESRD) statistics
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Incidence has increased 8%/yr for past 5 years
-280,000 CRF -65% on hemodialysis -28% have functioning transplants -7% receiving peritoneal dialysis |
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Pathophysiology [Chronic Renal Failure (ESRD)]
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Progressive, irreversible deterioration in renal function resulting in uremia or azotemia
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Azotemia- medical condition characterized by abnormal levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood.
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Conditions resulting in ESRD
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-Diabetes mellitus (leading cause)
-Hypertension -Chronic glomerulonephritis -pyelonephritis -obstruction of urinary tract -polycystic kidney disease -vascular disorders -medications or toxic agents |
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Stages of Chronic Kidney Disease
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Chart 44-3 in textbook
1-5 1- minimal kidney damage with normal glomerular filtration rate 2- mild w/ mildly decreased GFR 3- Moderate with moderate 4- severe with severe decrease 5- failure, ESRD with no GFR |
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Clinical Manifestations - Cardiovascular [Chronic Renal Failure (ESRD)]
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-hypertension - Na+ and water retention
-heart failure -pulmonary & peripheral edema -pericarditis from uremic toxins - orthostatic hypotension |
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Clinical Manifestations - Dermatological [Chronic Renal Failure (ESRD)]
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-pruritus
-uremic frost: White crystals in and on the skin -decreased skin turgor - yellow cast to skin - bruising |
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Clinical Manifestations - Gastrointestinal [Chronic Renal Failure (ESRD)]
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-anorexia
-N&V -hiccups -uremic fetor: Ammonia odor to breath |
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Clinical Manifestations - Neurologic [Chronic Renal Failure (ESRD)]
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-altered LOC
-inability to concentrate -muscle twitching -agitation -confusion -peripheral neuropathy |
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More Clinical Manifestations (CRF)
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Chart 44-4 in Textbookl-
Renal-polyuria, nocturia, oliguria, anuria, proteinuria, hematuria and dilute urine color |
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Medical Management: Pharmacologic [Chronic Renal Failure (ESRD)]
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-Phosphate binding agents
-calcium supplements -anti-hypertensives -cardiac medications -anti-seizure medications -erythropoietin (Epogen) |
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Medical Management: Nutrition [Chronic Renal Failure (ESRD)]
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-Careful regulation of protein, fluid, sodium, potassium intake (high biologic value proteins) (fluid intake based on output from previous day)
-vitamin supplementation |
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Dialysis
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-removes fluid and uremic waste products when kidneys unable to
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Hemodialysis
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-Most common
-Synthetic semipermeable membrane replacing renal glomeruli and tubules as filter -usually 3x per week for 3-4 hours -uses principles of diffusion, osmosis and ultrafiltration |
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Vascular Access Devices
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-Double lumen large bore cath into subclavian, internal jugular or femoral vein - used no more than 3 weeks
---Double lumen cuffed cath (Quinton) -arteriovenous fistula (AV fistula) ---Anatamose artery to a vein (side to side or end to side) ---Accessed with needles -Arteriovenous Graft (AV Shunt) ---Placing synthetic graft between artery and vein ---Graft can be used within 10 days |
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Complications of Dialysis
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-Bleeding - exsanguination (= The fatal process of total blood loss.)
-gastric ulcers -sleep disturbances -hypotension -painful muscle cramping -dysrhythmias -air embolism -chest pain -dialysis disequilibrium - CSF shifts |
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Nursing Management of ARF or CRF (ESRD)
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-Monitor weight, vs, cardiovascular status
-Monitor fluid & electrolyte balance -Monitor nutritional status -Administer appropriate medications ---Need to distinguish dialyzable meds from those which are not removed by dialysis ---Clarify meds given during or after dialysis -Address psychosocial needs ---Lifestyle altered with dialysis -Patient education ---Diet, meds, dialysis, restrictions in activity -Discharge planning |
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Continuous Renal Replacement Therapy (CRRT)
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-Therapy for ACR (acute or chronic renal failure), ESRD pts who are too clinically unstable for hemodialysis
-CRRT does not produce rapid fluid shifts and does not require dialysis machine -Hemofilter used in all methods |
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Types of Continuous Renal Replacement Therapy
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-Continuous Venovenous Hemofiltration
-Continuous Venovenous Hemodialysis -Peritoneal Dialysis |
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Continuous Venovenous Hemofiltration (CVVH)
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-Blood from double lumen pumped through hemofilter and returned by same cath
-Removes fluid slowly from the blood |
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Continuous Venovenous Hemodialysis
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-Same as hemofiltration, but uses concentration gradient to facilitate removal of toxins
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Peritoneal Dialysis
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-Peritoneum serves as semipermeable membrane. Dialysate introduced into abdomen, sits in abdomen and toxins removed by diffusion, then drained. Takes 36-48 hrs to do what hemodialysis does in 6-8 hours
---Acute Intermittent ---Continuous Ambulatory Peritoneal Dialysis (CAPD) |
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Continuous Ambulatory Peritoneal Dialysis (CAPD)
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-peritoneal cath implanted through abdominal wall
-Dacron cuffs and tunnel approach decreases infection -Dialysate flows by gravity into peritoneal cavity, dwells and drained. |
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Complications of Peritoneal Dialysis
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-Peritonitis
-Leakage -Bleeding |
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Nursing Management of Dialysis Patient
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-Protecting Vascular Access!
-Caution with IV rates to prevent hypervolemia -Monitor s/s of uremia/azotemia -Monitor for cardiac and respiratory complications (fluid overload, heart failure, pulmonary edema, pericarditis) -Monitor diet and electrolyte levels -pain relief -prevent infection -administer medications cautiously - monitor therapeutic levels |
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Protecting Vascular Access
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-No blood draws or BP in affected limb
-Assess bruit or thrill over site q 8 hrs -Assess for s/s of infection |
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