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
4
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
5
What additional information do you need?
Subjective information Objective information Psychosocial information
Informal evaluation
6
WBC in CBC is 15,000 Urine culture shows 120,000 bacteria CFU
(colony forming units)
Additional information for DK
7
Anatomy of the nephron
8
Location of the kidney
9
Relative size of the kidney
10
Renal xray
11
Removal of waste Fluid and electrolyte balance Acid-base balance Blood pressure Red blood cell production
Functions of the kidney
12
Conserve: water is concentrated
compared to plasma
Rid: water is dilute relative to
plasma
How kidneys influence fluid and electrolyte balance
13
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
14
Urine specific gravity
15
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
16
Reabsorption of bicarbonate filtered at the glomerulus
Work in compensatory mode with lungs
How kidneys maintain acid-base balance
17
↓ 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
18
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
19
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
20
↑ susceptibility to drug
overdose
↑ probability of
hyperkalemia
↑ propensity to dehydration
↓ fluid intake ↓ response to fluid overload
General consequences of age related changes
21
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
22
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
23
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
24
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
25
Consequences of renal failure
26
Causes of Acute Renal Failure
27
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
28
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
29
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
30
Diabetes Benign prostatic hyperplasia Hypertension Long-term NSAID use
Common causes of chronic renal failure specific to the older adult
31
Pruritis Malaise Generalized edema Cognitive changes Anorexia Nausea Weight loss
Common symptoms of chronic renal failure in the older adult
32
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
33
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
34
New urinary urgency Decreased flow initiation time Voiding > 7 times in 24 hours
When to consider UTI
35
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
36
“I didn’t want to bother you, Honey!”
“The Problem With A GU Problem”
37
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
38
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)
39
Neurogenic—inability to sense urge to void; MS, cerebral cortex lesions
Functional—prevented from reaching restroom; dementia, disabilities, sedation, inaccessibility
Types of incontinence (2)
40
Drugs Infection Atrophic vaginitis Psychological (depression, delirium,
dementia) Endocrine (hyperglycemia, hypercalcemia) Restricted mobility Stool impaction
Assessing new onset incontinence
41
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
42
Women: fecal impaction Men: prostatic hypertrophy
Regardless of cause, urinary retention can lead to urinary tract infection!
Common causes of urinary retention
43
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
44
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
45
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
46
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
47
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
48
Methods are mammography, clinical breast exam, self breast exam
Annual mammography for all women over 40
Breast cancer screening
49
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
50
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
51
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
52
What is your nursing diagnosis for DK?
What is your desired outcome?
What are appropriate interventions pertinent to your desired outcome?
Formal evaluation