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What is “spaghetti?”

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

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What is “spaghetti?”

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  1. What is “spaghetti?”

  2. “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. Patient Scenario • 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

  5. Informal evaluation What additional information do you need? • Subjective information • Objective information • Psychosocial information

  6. Additional information for DK • WBC in CBC is 15,000 • Urine culture shows 120,000 bacteria CFU (colony forming units)

  7. Anatomy of the nephron

  8. Location of the kidney

  9. Relative size of the kidney

  10. Renal xray

  11. Functions of the kidney • Removal of waste • Fluid and electrolyte balance • Acid-base balance • Blood pressure • Red blood cell production

  12. How kidneys influence fluid and electrolyte balance

  13. How kidneys control water excretion • 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

  14. Urine specific gravity

  15. How kidneys influence sodium balance • 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

  16. How kidneys maintain acid-base balance • Reabsorption of bicarbonate filtered at the glomerulus • Work in compensatory mode with lungs

  17. How kidneys influence blood pressure

  18. How kidneys influence red blood cell production • Kidney secretes erythropoietin • Erythropoietin acts on the bone marrow to increase red blood cell production • Promotes red blood cell survival

  19. Normal age related changes • 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

  20. General consequences of age related changes

  21. Age related changes in bladder and urethra • Hypertrophy of the bladder muscle • Thickening of the bladder wall • Decreased ability of the bladder to expand • Reduced storage capacity

  22. Changes in male reproductive system • Testes become less firm • ↓testosterone production → ↓ muscle mass and facial & body hair • Prolonged arousal time, time before climax, and refractory time

  23. Changes in female reproductive system • 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

  24. Renal failure in the older adult • 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

  25. Consequences of renal failure

  26. Causes of Acute Renal Failure

  27. Pre-renal causes of kidney failure 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

  28. Intrarenal causes of kidney failure 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

  29. Post-renal causes of kidney failure Due to factors affecting urine outflow • Obstruction of bladder or ureters • Prostatic hypertrophy, cancer • Tumors of the abdomen • Kidney stones

  30. Common causes of chronic renal failure specific to the older adult • Diabetes • Benign prostatic hyperplasia • Hypertension • Long-term NSAID use

  31. Common symptoms of chronic renal failure in the older adult • Pruritis • Malaise • Generalized edema • Cognitive changes • Anorexia • Nausea • Weight loss

  32. Teaching points for renal health • 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

  33. Urinary tract infection • 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

  34. When to consider UTI • New urinary urgency • Decreased flow initiation time • Voiding > 7 times in 24 hours

  35. Be alert to these symptoms • 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

  36. “The Problem With A GU Problem” “I didn’t want to bother you, Honey!”

  37. Medical treatment of UTI • Trimethoprim-sulfamethoxazole(Bactrim) has become less effective due to resistance • Fluouroquinolones used instead • Nitrofurantoin 100 mg BID • Men require longer treatment

  38. Types of incontinence (1) • Stress—weak pelvic muscles; laughing, sneezing coughing • Urgency—irritation of bladder wall; UTI, BPH, tumor • Overflow—bladder muscles are overextended, retained urine overflows

  39. Types of incontinence (2) • Neurogenic—inability to sense urge to void; MS, cerebral cortex lesions • Functional—prevented from reaching restroom; dementia, disabilities, sedation, inaccessibility

  40. Assessing new onset incontinence • Drugs • Infection • Atrophic vaginitis • Psychological (depression, delirium, dementia) • Endocrine (hyperglycemia, hypercalcemia) • Restricted mobility • Stool impaction

  41. Treatment of incontinence • Stress: Kegel exercises, medications, surgery • Urgency: Kegel exercises, medications, toileting schedule • Overflow: toileting schedule, medications, Credemethod • Lifestyle modifications: • Smoking cessation • Weight reduction • Bowel management • Caffeine reduction • Monitoring fluid intake

  42. Common causes of urinary retention • Women: fecal impaction • Men: prostatic hypertrophy • Regardless of cause, urinary retention can lead to urinary tract infection!

  43. Notes on benign prostatic hyperplasia • Obstruction of the vesical neck and compression of the urethra • Hesitancy, decreased stream, frequency, nocturia • May produce dribbling, poor control, overflow incontinence and bleeding

  44. Diagnostics for BPH • PSA • Normal = < nanograms • 4-10 nanograms = 25% chance of cancer • > 10 nanograms = 50%+ chance of cancer • Cystoscopy • Ultrasound • Intravenous pyelogram • Urodynamic studies

  45. Treatment of BPH • 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

  46. Menopause concerns • 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

  47. Gynecological screening • 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

  48. Breast cancer screening • Methods are mammography, clinical breast exam, self breast exam • Annual mammography for all women over 40

  49. Benefits of HRT • 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

  50. Risks of HRT • 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

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