Exam I

Pathogenesis of ascites

(1) portal HTN (2) hypoalbuminemia (3) secondary hyperaldosteronism - decreased CO, activates RAS, liver is unable to metabolize aldosterone

Functions of Liver: Carbohydrate Metabolism

(amino acids and fatty acids)

Major Functions of the Liver

-carbohydrate metabolism -lipid metabolism -protein metabolism -storage -blood filtering -detoxification -secretion of bile -blood clotting -secretion of bilirubin -blood (temporary) storage -stores glucose in form of glycogen; vitamins, including fat soluble (A,D,E,K) and water soluble (B, cobalamin, folic acid); fatty acids, minerals (iron, Cu); and amino acids in form of albumin and beta-globulins

Normal Mg levels

1.5-2.5 mEq/L

Normal Hemoglobin levels

12-18 g/dL

Normal Na levels

135-145 mEq/L

Normal PLT count

150,000-400,000

Normal phosphorus levels

2.5-4.5 mg/dL

Normal K levels

3.5-5.0 mEq/L

Normal CO2 levels

35-45 mmHg

Normal hematocrit values

35-50%

Normal WBC count

5,000-10,000/mm3

Normal glucose levels

60/70-110 mg/dL (fasting) non-fasting <120

Pancreas Anatomy

Acinar Cells: Synthesize digestive enzymes Pancreatic Duct: Delivers enzymes to duodenum Ampulla of Vater: (hepatopancreatic sac like enlargement) formed by the pancreatic duct & CBD Sphincter of Oddi: (smooth muscle) controls introduction of bile & pancreatic secretions into the duodenum Duodenal Papilla: opening into the small intestine

Acute Pancreatitis

An acute inflammatory process of the pancreas Degree of inflammation varies from mild edema to severe necrosis. •Severity of disease varies according to extent of pancreatic destruction. •Is classified as either mild pancreatitis (edematous or interstitial pancreatitis) or severe pancreatitis (necrotizing pancreatitis). Acute pancreatitis can be life threatening. • Some patients recover completely, others have recurring attacks, and chronic pancreatitis develops in others.

Esophageal Banding

Endoscopic variceal ligation Elastic band applied over varices to control acute bleeding by preventing blood flow to varices causing necrosis and eventual sloughing

Paracentesis

Nursing Care: •Empty bladder •Assist with positioning •Monitor BP •May need albumin •Monitor for complications •Manage drainage if any

Peritoneal Dialysis

Peritoneum as the dialyzing membrane §Parietal—lines inside of abdominal wall §Visceral—covers abdominal organs making many folds §Blood vessels located in intestines §Tenckhoff one of the most common catheters used.

Therapies for Elevated Potassium Levels

Regular insulin IV (with Dextrose 50%): forces K into cells from intravascular bed; dext carried into cell, which drives K into cell (emergent method) Sodium Bicarbonate: used for metabolic acidosis, but a high Na load, so not used as much Calcium Gluconate IV: Ca preserves contractility of myocardium (emergent method) Hemodialysis: need access line and team of people trained, machine; good solution, but not quick Sodium Polystyrene Sulfonate (Kayexalate): good solution, but not quick. Orally or via enema; binds with K, and is removed via stool Dietary restriction:

liver function tests (LFTs)

group of blood tests that evaluate liver injury, liver function, and conditions commonly associated with the biliary tract

Classification of Jaundice

inability to conjugate and excrete bilirubin into the small intestine + obstruction (compression) of biliary ducts

Processes Involved in Hemodialysis

§Concentration Gradient §Diffusion §Osmosis §Ultrafiltration

Hepatitis Clinical Manifestations - Acute Phase

§Lasts from 1 to 4 months §May be icteric (symptomatic) or anicteric §During incubation, symptoms include ¢Malaise ¢Anorexia ¢Fatigue ¢Nausea ¢Mild, flulike symptoms ¢Occasional vomiting ¢Abdominal discomfort ¢Headache ¢Low-grade fever ¢Arthralgias ¢Skin rashes §Physical exam may reveal hepatomegaly, lymphadenopathy, and splenomegaly. §Maximal infectivity period

Postrenal Causes of AKI

§Mechanical obstruction of outflow of urine (unilateral less of a problem) §If relieved within 48 hours of onset prognosis is good §< 10% of all AKI §Will discuss with BPH

Kidney Failure

§Partial or complete impairment of kidney function §See 46-1 (2017)

Kidney Cancer Clinical Manifestations & Diagnostic Studies

•No characteristic early symptoms •Gross hematuria, flank pain, palpable mass •Other: weight loss, fever, HTN, anemia •Signs of mets •Dx: CT/US + others Many patients go undiagnosed until the cancer is significantly progressed

Urinary Tract Calculi Extracorporeal Shock Wave Lithotripsy (ESWL)

•Spinal or general; outpatient •Ultrasonic shock waves directed at kidney using a lithotripter (stone crusher) •Hematuria seen post; ureteral stent may be in place for 1 to 2 weeks •Contact your physician immediately if you experience any of the following symptoms: •Heavy bleeding or bleeding that is not clearing up after 24 hours of the procedure •Pain not controlled by prescribed medication •Fever above 100 degrees Fahrenheit •Continuous Nausea and vomiting •Difficulty urinating •Diet should be high in liquids What is the treatment for stones that do not pass on their own? Lithotripsy is a procedure that uses shock waves to break a kidney stone into smaller pieces that can be more easily expelled from the body. The device used for this procedure is called a Lithotripter. Kidney stones can also be removed surgically. A percutaneous nephrolithotomy is a procedure in which a kidney stone is removed via a small incision in the skin. A kidney stone may also be removed with a ureteroscope, an instrument that is advanced up through the urethra and bladder to the ureter. http://www.medicinenet.com/kidney_stone_pictures_slideshow/article.htm •Laser lithotripsy is used to break up ureteral and large bladder stones. Ureteroscopy is used to get close to the stone. A small fiber is inserted up the endoscope so that the tip (which emits the laser energy) can come in contact with the stone. A holmium laser in direct contact with the stone is commonly used to break up the stone. •In extracorporeal shock-wave lithotripsy (ESWL), the patient receives anesthetic (spinal or general) to ensure that the patient's position is maintained during the procedure. Fluoroscopy or ultrasonography is used to focus the lithotripter on the affected kidney, and a high-voltage spark generator produces high-energy acoustic shock waves that shatter the stone without damaging the surrounding tissues. The stone is broken into fine sand (steinstrasse) and excreted in the urine. •In percutaneous ultrasonic lithotripsy, an ultrasonic probe is placed in the renal pelvis via a percutaneous nephroscope inserted through a small incision in the flank, and the probe is then positioned against the stone. The patient is given general or spinal anesthetic, and the probe produces ultrasonic waves, which break the stone into sandlike particles. •In electrohydraulic lithotripsy, the probe is positioned directly on a stone, but it breaks the stone into small fragments that are removed by forceps or by suction. A continuous saline irrigation flushes out the stone particles, and all of the outflow drainage is strained so that the particles can be analyzed. The calculi can also be removed by basket extraction. •Depending on the lithotripter used, the patient is either submerged in warm water in a very large specially designed bathtub for approximately one hour for the treatment, or positioned on a specially designed treatment table for the procedure. High resolution x-ray system and digital fluoroscopy assist in properly positioning the patient so the stone(s) receives the strongest impact of shock waves created by a special electrode. These shock waves are created outside the body and then travel through the skin and tissue until they hit the dense stone. Depending on the type and location of your stone, you will receive from 800 to 3000 shock waves. Once the stone is in sandlike particles, you are transferred to a recovery area. • Though protocols vary from one facility to the next, a typical day will somewhat resemble the following: Arrive at the facility 1-2 hours before the scheduled time for any labs, x-rays and pre-operative medications. Be sure to bring all necessary insurance information, and a list of your current medications and dosages. Many facilities want you to bring your medications with you in the original containers. In the holding area your anesthesiologist, urologist and technician working with the urologist will come talk to you and verify the treatment site of your stone. Please ask if you have any questions or need clarification of information given. Depending on the facility, some type of imaging (x-ray or ultrasound) will be used to locate the stone for targeting and treatment. A coupling medium such as water or get will be applied between the patient and the shockwave source. Once the patient is comfortable, the anesthesiologist will provide sedation medication. Patients may hear a clapping sound produced by the lithotripter machine. The actual treatment will last 30-45 minutes. During this procedure it is very important to remain as still as possible. When a patient moves, the stone moves. Stone movement inhibits the successful targeting of the stone, resulting in less than ideal fragmentation. Imaging will be used at times during the entire procedure to ensure proper stone position. Following the procedure, you will be taken to the recovery area. You may be in the recovery area for 1-2 hours. Recovery personnel may ask you to do the following prior to discharge: Stand and bear your own weight Urinate Have a light snack Make sure you understand your discharge instructions http://www.mwstone.com/kidney_lithotripsy.php After the procedure is completed you will be given instructions to follow upon discharge. These instructions will ensure a more successful, safe and comfortable outcome. The process of passing stone fragments may take hours, days, or weeks. Every patient is unique and it is very important to follow the instructions given when leaving the facility. This not only promotes your safety but also aides your physician in monitoring progress following treatment. Most patients will pass blood in the urine after the procedure. This is to be expected. Some patients, especially those with large stones, experience discomfort, fever or intestinal upset as the stone particles pass. Discomfort levels vary from none to a level of pain requiring narcotic pain relievers; however, most patients have very little discomfort and mild pain tablets are usually all that are needed. It will take from two weeks to three months for most of the granular particles to be washed from the kidney. Contact your physician immediately if you experience any of the following symptoms: Heavy bleeding or bleeding that is not clearing up after 24 hours of the procedure Pain not controlled by prescribed medication Fever above 100 degrees Fahrenheit Continuous Nausea and vomiting Difficulty urinating Patients undergoing lithotripsy will normally be outpatients and be able to go home the same day. After treatment, a diet high in liquids will be recommended to aid in passage of the stone fragments. Total recovery time after lithotripsy treatment is only one week or less. During the months following treatment, there is an excellent possibility that you will pass all of your stone fragments. However, even if you do not, in most cases these stones cause no symptoms and do not require further treatment. Remember to make your return appointment with your urologist to follow-up on your care after your procedure.

Hepatitis Clinical Manifestations - Convalescent Phase

Begins as jaundice is disappearing Lasts weeks to months Major complaints ¢Malaise ¢Easy fatigability ¢Almost all cases of hepatitis A are resolved. ¢Absence of jaundice does not mean recovery.

Automated Peritoneal Dialysis Cycler

Can be used while the patient is sleeping or for hospitalized patients who require frequent exchanges

Prostate Cancer

•1 in every 6 men will develop it in their lifetime. •Most common cancer among men, excluding skin cancer •Second leading cause of cancer death in men •Androgen-dependent adenocarcinoma •Slow growing •Risk factors •Nonmodifiable: age, ethnicity, family history •High fat, High red meat, low fruit and vegetable diet •It is estimated that 241,740 new cases of prostate cancer are diagnosed, and 28,170 men die annually from the disease in the United States. •Skin cancer is the most common cancer; lung cancer is the leading cause of cancer death among men. •The majority (more than 60%) of cases occur in men over age 65. However, many cases occur in younger men who sometimes have a more aggressive type of cancer. •Almost 2.8 million men in the United States are survivors of prostate cancer. §Known risk factors Age, ethnicity, and family history are non-modifiable risk factors. Incidence rises markedly after age 50. Median age at diagnosis is 67 years old. Highest in Jamaican men of African descent Having a first-degree relative with prostate cancer increases risk. •Additional information on ethnicity is presented in the Cultural and Ethnic Health Disparities box in Chapter 55. •The reasons for the higher rate in African Americans are unknown. •African American men are also likely to have more aggressive tumors at diagnosis and have higher mortality rates from prostate cancer. §Dietary factors and obesity may be associated with prostate cancer. High red and processed meat intake Diet with high-fat dairy products Diet low in vegetables and fruits §Not clear if smoking is a risk factor §Not clear if having BPH puts men at greater risk •The role of dietary carotenoids (e.g., lycopene) and antioxidants (e.g., vitamins D and E and selenium) and prostate cancer risk is not clear. •A large research study found that men who took vitamin E had an increased incidence of prostate cancer with selenium supplements showing no benefit. No single gene is the cause. No genetic tests available to determine if a man is predisposed to developing prostate cancer Having a family history does not mean it is certain a man will develop prostate cancer. Genetic counseling may be indicated. •If men have a family history of prostate cancer, they should first talk with their health care provider about their concerns. •It is important for the health care provider to obtain a detailed family history including a family pedigree. •Depending on the findings of the family history, a referral to a genetic counselor may be appropriate. Age: incidence rises markedly after age 50 Ethnicity: Higher in African Americans Family hx of prostate CA in 1st degree relatives Use of Proscar: reduced chance of prostate CA by 25%! Uncontrollable Risk Factors Aging in men (beginning at age 50) is the greatest risk factor for both BPH and prostate cancer. In addition, having a father or brother with prostate cancer doubles the risk for prostate cancer; however, African American males have the highest risk for prostate cancer. Research suggests that the majority of men at age 70 have some form of prostatic cancer with most of them showing no symptoms. Controllable Risk Factors Researchers suggest a diet low in fruits and vegetables but high in meats and high-fat dairy products increases the risk for prostate cancer. The mechanism(s) for this is being investigated but current speculation suggests meat and high-fat foods contain compounds that augment the growth of cancer cells. Cancer-Conscious Diet As stated previously, a good diet and lifestyle may help lower the risk for prostate cancer; the same is true for those men diagnosed with prostate cancer in terms of cancer recurrence. Consequently, it is appropriate to review diet and lifestyle changes: Increase frequency and portion sizes of fruits and vegetables Eat whole grains and avoid processed grains and white flour Reduce or stop eating high-fat dairy products and meats, especially processed meats ljke bacon, sausage, and baloney Limit or eliminate alcohol Some research suggests that spinach, orange juice, and other foods may decrease the risk of cancer; prostate cancer patients may get additional diet and lifestyle recommendations when they follow up with their doctors. Beware of Supplements Prostate cancer patients and other cancer patients should be very cautious about taking supplements and other items marketed as cancer preventives or cures. Before taking any such compounds, the person should discuss the compound with their doctor. In addition, cancer patients are advised not to self-medicate or change medication dosages without first conferring with their doctor(s). http://www.medicinenet.com/slideshows/article.htm Because of their increased risk of prostate cancer, African American men and other men with a family history of prostate cancer should have an annual PSA and DRE beginning at age 45.

Pre-Renal Causes of AKI

-Factors that ↓ RBF→ ↓GFR -No damage to kidneys if reversed -Hallmark findings: oliguria, urine sodium <20 mEq/L + azotemia -If prolonged→ischemic intrarenal disease -Health Promotion & Treatment -Key is to prevent or recognize & RX stat

Acute Kidney Injury

-Sudden loss of renal function -Usually reversible -Primary goals of treatment -See Table 46-2 for specific causes of 3 types of AKI

Normal Amylase level

25-151 (look this up)

Normal Ca levels

8.5-10.5 mg/dL

Normal Cl levels

95-105 mEq/L

Diagnostic Studies - cholecystitis

Abdominal ultrasound (most common) §Before: Instruct patient to be NPO for 8-12 hr. Food intake can cause gallbladder contraction, resulting in suboptimal study. Percutaneous transhepatic cholangiography §Before: Assess patient's medications for possible contraindications, precautions, or complications with use of contrast medium. Keep patient NPO for 8-12 hr before test. Initiate prophylactic IV antibiotics 1 hr prior. §After: Observe patient for signs of hemorrhage, bile leakage, and infection. Observe safety precautions until sedation wears off. Maintain bed rest for 6 hr. ERCP •Ultrasound is commonly used to diagnose gallstones. •It is especially useful for patients with jaundice (because it doe not depend on liver function) and for patients who are allergic to contrast medium. •ERCP allows for visualization of the gallbladder, cystic duct, common hepatic duct, and common bile duct. Bile taken during ERCP is sent for culture to identify possible infecting organisms. •Percutaneous transhepatic cholangiography is the insertion of a needle directly into the gallbladder duct, followed by injection of contrast materials. It is generally done after ultrasonography indicates a bile duct blockage.

Acute Pancreatitis Nursing Implementation

Acute intervention ◦Monitoring vital signs for... ◦IV fluids ◦Assessment of respiratory function ◦Pain assessment and management IV Opioids Frequent position changes Side-lying with HOB elevated 45 degrees Knees up to abdomen...most comfortable with trunk flexed. Safety Alert: Assess for respiratory distress & listen to lungs & check sat regularly •Hemodynamic stability may be compromised by hypotension, fever, and tachypnea.. IV Fluid and electrolyte replacements are commonly given. Ensure good IV access and know how to give safely. Monitor for s & s of shock: hypovolemic and septic or both. Observation for signs of infection. •Close monitoring of respiratory status with oxygen administration. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths. Measures to prevent respiratory infection include turning, coughing, deep breathing, and assuming a semi-Fowler's position. •Pain and restlessness can increase the metabolic rate and subsequent stimulation of pancreatic enzymes. Patient will require an opioid, morphine to manage pain. •Measures such as comfortable positioning, frequent changes in position, and relief of nausea and vomiting assist in reducing the restlessness that usually accompanies the pain. Abdominal distention can interfere with positioning. Assuming positions that flex the trunk and draw the knees up to the abdomen may decrease pain. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain.

UTI Drug Therapy: Complicated

Antibiotics (7-14 days) •Fluoroquinolones •Levofloxacin (Levaquin) •Ciprofloxacin (Cipro) •Amphotericin for fungal UTI •Prophylactic or suppressive •A low dose of TMP/SMX, nitrofurantoin, or another antibiotic may be administered on a daily basis in an attempt to prevent recurring UTIs, or a single dose may be taken before an event likely to provoke a UTI, such as sexual intercourse. • Although suppressive therapy is often effective on a short-term basis, this strategy is limited because of the risk of antibiotic resistance. •Emphasize taking full course of antibiotics despite disappearance of symptoms.

Acute Pancreatitis Nursing Implementation (cont'd)

Acute intervention (cont'd): Nutrition ◦Keep NPO ◦NG suction and NG tube care Decreases gastric HCL acid secretion and subsequent stimulation of pancreatic enzymes Relieves urge to vomit and decreases abdominal distention Treats associated ileus Helps to prevent aspiration ◦Frequent oral/nasal care ◦Progress diet as tolerated...may need enteral via jejunal tube/Central TPN •Goal is to suppress pancreatic enzymes to decrease stimulation of the pancreas and allow it to rest. •As advance diet: small, frequent feedings, high in carbohydrates since least stimulating to the exocrine portion of the pancreas. Fats stimulate release of cholecystokinin, which then stimulates the pancreas. Suspect intolerance if: reports pain, increase abdominal girth, or increase serum amylase and lipase. Abstain from ETOH. May need supplemental fat-soluble vitamins.

Urinary Tract Calculi Etiology and Pathophysiology

Aka nephrolithiasis, urolithiasis Risk factors •Metabolic (UA) •Climate (Hot) •Diet (UA) •Family history •Lifestyle (sedentary) •Recurrent •See Table in textbook for Risk Factors Kidney stones are small composites of salts and minerals that form inside the kidneys and may travel down the urinary tract. Kidney stones range in size from just a speck to as large as a ping pong ball. About 5% of people develop a kidney stone in their lifetime. http://www.medicinenet.com/kidney_stone_pictures_slideshow/article.htm Metabolic factors: abnormalities result in increased urine calcium, oxaluric acid, uric acid, or citric acid Climate: Summer when hot thus supporting the role of dehydration in this process. ...increased fluid loss, low urine volume, increased solute concentration in urine. Keeping urine dilute and free flowing reduces the risk of recurrent stone formation in many individuals. Diet: number of dietary risk factors that causes...high protein intake which increases uric acid excretion; excessive tea or fruit juice (elevates urinary oxalate); high intake of calcium & oxalate; low fluid intake that increases urinary concentration Family history: Family history of stones; Caucasian ethnicity and male gender are associated with higher rates of kidney stones. Average age at onset: 20-55 years. Genetic factors may also contribute to urine stone formation. Lifestyle: sedentary occupation, immobility Recurrence: A person who has suffered from one kidney stone is likely to develop others. Stones can recur in up to 50% of patients.

Prostate Cancer: Nursing Implementation

Ambulatory and Home Care •Teach catheter care. •Teach pelvic floor exercises. •Administer pain medication. •Instruct the patient to clean the urethral meatus with soap and water once a day, maintain a high fluid intake, keep the collecting bag lower than the bladder at all times, keep the catheter securely anchored to the inner thigh or abdomen, and report any signs of bladder infection, such as bladder spasms, fever, or hematuria. •If urinary incontinence is a problem, encourage the patient to practice pelvic floor muscle exercises (Kegel exercises) at every urination and throughout the day. Continuous practice during the 4- to 6-week healing process improves the success rate. Products used for incontinence specifically designed for men are available through home care product catalogs and many retail stores. •Pain management is one of the most important aspects of your care for these patients. Pain control is managed through ongoing pain assessment, administration of prescribed medications (both opioid and nonopioid agents), and the use of nonpharmacologic methods of pain relief (e.g., relaxation breathing). •Common problems experienced by the patient with advanced prostate cancer include fatigue, bladder outlet obstruction, and ureteral obstruction (caused by compression of the urethra and/or ureters from tumor mass or lymph node metastasis), severe bone pain and fractures (caused by bone metastasis), spinal cord compression (from spinal metastasis), and leg edema (caused by lymphedema, deep vein thrombosis, and other medical conditions). Nursing interventions must focus on all of these problems.

UTI Drug Therapy: Uncomplicated

Antibiotics (1-3 days) •Trimethoprim/sulfamethoxazole (TMP/SMX) (Bactrim) •Nitrofurantoin (Macrodantin, Macrobid) •Ampicillin, Amoxacillin, Cephalosporins Empiric (best judgment of drug) vs. sensitivity testing. Usually only symptomatic are treated. Emphasize taking full course of antibiotics despite disappearance of symptoms. Antibiotics Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial UTI Inexpensive Taken twice a day E. coli resistance to TMP-SMX ↑ Nitrofurantoin (Macrodantin) NYE troe fyou RAN toe-in •Given three or four times a day •Long-acting preparation (Macrobid) is taken twice daily. Nitrofurantoin (Furadantin, Macrodantin) • Avoid sunlight. Use sunscreen; wear protective clothing. • Notify health care provider immediately if fever, chills, cough, chest pain, dyspnea, rash, or numbness or tingling of fingers or toes develops. Ampicillin, amoxicillin, cephalosporins Treat uncomplicated UTI

Bladder Cancer Clinical Manifestations/Warning Signs

Blood in urine: Microscopic or gross, painless hematuria Bladder Changes •Bladder irritability •Dysuria •Frequency •Urgency Warning Sign: Blood in Urine Microscopic or gross, painless hematuria One sign of bladder cancer is blood in the urine, although this is not a specific sign. Blood in the urine is most often caused by other conditions like trauma, infection, blood disorders, kidney problems, exercise, or certain medications. Blood in the urine may be seen by the naked eye or only detected on urine testing. The urine may be discolored and appear brownish or darker than usual or, rarely, bright red in color. Warning Sign: Bladder Changes Bladder cancer sometimes causes changes in bladder habits like feeling an urgent need to urinate, urinating more frequently than usual, pain on urination, or difficulty with urination. But these symptoms of bladder problems, like bleeding, are usually caused by conditions other than cancer. http://www.medicinenet.com/bladder_cancer_pictures_slideshow/article.htm

Clinical Manifestations: Cholelithiasis vs. Chronic Cholecystitis

Cholelithiasis §Silent or may be severe §Depends on if stones are stationary or moving and if obstruction present Chronic cholecystitis §Fat intolerance §Dyspepsia §Heartburn §Flatulence •Cholelithiasis may produce severe symptoms or none at all. Many patients have "silent cholelithiasis." The severity of symptoms depends on whether the stones are stationary or mobile and whether obstruction is present. •The patient with chronic cholecystitis may not have acute symptoms (silent) and may not seek help until jaundice and biliary obstruction occur. Manifestations of chronic cholecystitis may include a history of fat intolerance, dyspepsia, heartburn, and flatulence. Earlier detection in these patients is beneficial so they can be taught health promotion techniques with an emphasis on managing their diet by consuming a low-fat diet and being monitored by HCP more closely.

Gallbladder Disorders

Cholelithiasis §Stones in the gallbladder Cholecystitis §Inflammation; often R/T stone §Chronic --Swelling and irritation of the gallbladder that persists over time --Secondary to repeated acute attacks §Acute (sudden inflammation with abd pain) •The most common disorder of the biliary system is cholelithiasis (stones in the gallbladder). The stones may be lodged in the neck of the gallbladder or in the cystic duct. •Cholecystitis (inflammation of the gallbladder) is usually associated with cholelithiasis. Cholecystitis may be acute or chronic. Chronic cholecystitis is swelling and irritation of the gallbladder that persists over time. Chronic cholecystitis is usually caused by repeated attacks of acute (sudden) cholecystitis. Acute cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain. Most common stones are made of cholesterol.

Nursing Implementation - Hepatitis Ambulatory and home care

Dietary teaching Assessment for complications Regular follow-up for at least 1 year after diagnosis §Avoidance of alcohol §Medication education ¢Α-interferon administered subcutaneously ¢Side effects

Collaborative Care:Cholelithiasis

ERCP with Sphincterotomy §Visualization §Dilation §Placement of stents §Open the sphincter of Oddi, if needed §Endoscope passed to duodenum §Stones removed with basket or allowed to pass in stool §Post-procedure care --have to make sure they can swallow and have gag reflex before giving them any food •ERCP with endoscopic sphincterotomy (papillotomy) may be used for stone removal. ERCP allows for visualization of the biliary system, dilation (balloon sphincteroplasty), as well as the placement of stents and sphincterotomy if warranted. Special catheters with wire baskets or inflatable balloon tip may be used for stone removal. The endoscope is passed to the duodenum. With an electrodiathermy knife attached to the endoscope, the stone is commonly left in the duodenum to pass naturally in the stool. •When a stent is placed, it is generally removed or changed after a few months. Your care of the patient after ERCP with sphincterotomy includes assessment to detect complications such as pancreatitis, perforation, infection, and bleeding. Monitor the patient's vital signs. Abdominal pain and fever may indicate pancreatitis. The patient should be on bed rest for several hours and should be on NPO status until the gag reflex returns. Teach the patient the need for follow-up if the stent is to be removed or changed.

Case Study § A.L. is a 45-year-old mother of three who presents to the ED. § She is complaining of acute abdominal pain in her right upper quadrant. §She rates the pain as a 7 out of 10. § A.L. is 5 feet 3 inches tall and weighs 170 lb. §She works as a florist and does not exercise. What risk factors does A.L. have for gallbladder disease?

Female gender, obesity, age > 40 years, multiparity, sedentary lifestyle

Collaborative Care: Cholelithiasis Nutritional Therapy

Focus on Ineffective health management (diet) §Small, frequent meals with some fat §Diet low in saturated fat §High in fiber §Reduced-calorie diet if patient is obese §Avoidance of rapid weight loss •When the patient is managed conservatively, depends on the patient's symptoms and on whether surgical intervention is being planned, dietary teaching is usually necessary. •People have fewer problems if they eat smaller, more frequent meals with some fat at each meal to promote gallbladder emptying. •The diet should be low in saturated fats (e.g., butter, shortening, lard) and high in fiber and calcium. •If obesity is a problem, a reduced-calorie diet is indicated. Rapid weight loss should be avoided because it can promote gallstone formation. •Explain the importance of continued health care follow-up.

What is a cast?

Formed from gelled protein precipitated in the renal tubules and molded to the tubular lumen. Pieces of these casts break off and are washed out with the urine. Types named for their constituent material include epithelial, granular, hyaline, and waxy casts. In renal disease, casts may be seen containing red or white blood cells.

Clinical Manifestations (other): Acute Cholecystitis

GI symptoms §N/V; dyspepsia (burning/indigestion) §Eructation (belching) Manifestations of inflammation §Fever/Chills & leukocytosis SNS §Tachycardia §Restlessness §Diaphoresis Respiratory §Splinting (inspiratory pause) §Tachypnea Signs of obstruction: Jaundice •In addition to pain may experience: •GI symptoms: indigestion, N/V; Palpable gallbladder; Abdominal guarding and distention and rigidity •Manifestations of inflammation: Fever and leukocytosis. •SNS: Restlessness, tachycardia, diaphoresis. •Respiratory: splinting, tachypnea •Signs of obstruction: Jaundice + others

Urinary Diversion Nursing Management - Incontinent

Ileal conduit •Consult ostomy nurse pre-op •Will always need an appliance •Protect skin with barrier before applying ostomy bag •Urine will flow continuously and will contain mucus •Good fluid intake •Assess for healthy stoma •See eCarePlan Ileal Conduit: 6-8 inch segment of the ilium is converted into a conduit for urinary drainage. A colon conduit can be used instead The ureters are anastomosed into one end of the conduit and the other end of the bowel is brought out through the abdomen to form a stoma. No valve, no control over stoma, requires permanent external collecting device External collecting device. Stoma care. Life-long!! Main difference between various diversions is the segment of bowel used. Indiana uses right colon. Orthotopic Bladder reconstruction: New bladder constructed from intestines (low pressure reservoir) in normal anatomic position. Urinate through urethra Must have normal renal and liver function. No hx of inflammatory bowel disease or colon cancer. Obesity contraindicated. Can have incontinence. No normal urge to void. Empty bladder by relaxing their sphincter muscles and bearing down with their abdominal muscles. Should void every 2-4 hours to avoid overdistention.

Acute Pancreatitis Diagnostic Studies

Laboratory tests ◦Serum/urinary amylase ◦Serum lipase ◦CBC ◦Liver enzymes ◦Blood glucose ◦Triglycerides ◦Bilirubin ◦Serum calcium ◦Other electrolytes ◦ABG's Abdominal/Endoscopic ultrasound X-ray CT scan Endoscopic retrograde cholangiopancreatography (ERCP) •The primary diagnostic tests for acute pancreatitis are serum amylase and lipase measurements. •The serum amylase level is usually elevated early and remains elevated for 24 to 72 hours. •Serum lipase level, which is also elevated in acute pancreatitis, is an important test because other disorders (e.g., mumps, cerebral trauma, renal transplantation) may increase serum amylase levels. •Other findings include an increase in liver enzymes, triglycerides, glucose, and bilirubin levels and a decrease in calcium level. •Diagnostic evaluation of acute pancreatitis is also directed at determining the cause. •Abdominal ultrasonography, x-ray, or contrast-enhanced CT scanning can be used to identify pancreatic problems. •CT scanning is the best imaging test for pancreatitis and related complications such as pseudocysts and abscesses. •ERCP is can be used, although ERCP can cause acute pancreatitis in some cases. •Additional studies include endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), and angiography. •Chest x-rays may show pulmonary changes, including atelectasis and pleural effusions.

Robotic Surgery: daVinci® Prostatectomy (dVP)

Laparoscopic, robotic assisted allows for increased precision and visualization and dexterity by surgeon. Similar outcomes and improved recovery times. A robotic-assisted (e.g., da Vinci system) prostatectomy is a type of laparoscopy in which the surgeon sits at a computer console while controlling high-resolution cameras and microsurgical instruments. Robotics are being used more as they allow for increased precision, visualization, and dexterity by the surgeon when removing the prostate gland. Compared with traditional approaches, a robotic-assisted radical prostatectomy has resulted in similar surgical outcomes with improved recovery time.

Cirrhosis Clinical Manifestations

Liver inflammation (causing pain, fever-->N/V-->fatigue) Liver necrosis (dec bilirubin, protein, carb, fat metabolism-->altered hormone metabolism-->inc AST, ALT, bilirubin, PTT, albumin-->liver failure-->hepatic encephalopathy-->hepatic coma-->death Liver fibrosis and scarring-->portal HTN-->ascites, edema, splenomegaly, thrombocytopenia, leukopenia, varices

Pancreas Physiology

Major disorder: Pancreatitis •Exocrine function -Controlled by 2 hormones in duodenum •Secretin •Cholecystokinin -Digestive enzymes •Trypsin •Lipase •Amylase •Normally inactive in pancrease to prevent autodigestion •Become active once delivered to duodenum Major disorder: Diabetes •Endocrine function -Islets of Langerhans •Alpha: glucagon •Beta: insulin •Delta: somatostatin

Urinary Tract Calculi Collaborative Care

Manage acute attack •Pain management --Opioids •Infection •Obstruction --Tamsulosin (Flomax) --Terazosin (Hytrin) •Assessment of cause What is the treatment for kidney stones? Manage an acute attack: •Administer opioids to relieve renal colic pain. Pain can be severe! Top priority. •Tamsulosin (Flomax) or terazosin (Hytrin), α-adrenergic blockers that relax the smooth muscle in the ureter, can be used to facilitate stone passage by relaxing the smooth muscle in the ureters. These drugs may also relax the muscle of the prostate in men with benign prostatic hyperplasia (BPH). •May need antibiotics. •Most people with kidney stones are able to pass them on their own within 48 hours by drinking plenty of fluids. Pain medication can ease the discomfort. The smaller the stone, the more likely it is to pass without intervention. Other factors that influence the ability to pass a stone include pregnancy, prostate size, and patient size. Stones that are 9 mm or larger usually do not pass on their own and require intervention. Stones that are 5 mm in size have a 20% chance of passing on their own while 80% of stones that are 4 mm in size have a chance of passing without treatment. http://www.medicinenet.com/kidney_stone_pictures_slideshow/article.htm •Assessment of Cause and Prevention of further stone development •The second approach is directed toward evaluation of the cause of the stone formation and the prevention of further stone development. Patient and family history Geographic residence Nutritional assessment Activity patterns Immobilization or dehydration Surgery of GI or GU tract

Collaborative Care: Minimally Invasive Therapies ...FYI (See table 54-3 for overview)

Minimally Invasive Therapies •Becoming more common •Destroy prostatic tissue -Lasers (VLAP) -Radiofrequency (TUNA) -Microwaves (TUMT) -Intraprostatic Urethral Stents •They generally do not require hospitalization or catheterization and are associated with few adverse events. •Many have shown outcomes comparable to invasive techniques.

Immediate Postoperative Care: Laparoscopic Cholecystectomy

Monitor for complications Patient comfort (Focus on Acute Pain) §Referred pain to Right shoulder pain from CO2 §CO2 irritation of phrenic nerve & diaphragm affects breathing §Sims' position (left side with right knee flexed moves gas pocket from diaphragm) §Deep breathing, ambulation, §Analgesia Most discharged same day •Postoperative nursing care following a laparoscopic cholecystectomy includes monitoring for complications such as bleeding, making the patient comfortable, and preparing the patient for discharge. •A common postoperative complaint is referred pain to the shoulder because of the carbon dioxide (CO2) that is used to inflate the abdominal cavity during surgery. It may not be released or absorbed by the body. The CO2 can irritate the phrenic nerve and diaphragm, causing some difficulty in breathing. Placing the patient in the Sims' position (left side with right knee flexed) helps move the gas pocket away from the diaphragm. •Encourage deep breathing along with movement and ambulation. •The pain can usually be relieved by NSAIDs or codeine. The patient is allowed clear liquids and can walk to the bathroom to void. Most patients go home the same day.

Acute Pancreatitis Etiology/Risk Factors

Most common in middle-aged men and women Affects women and men equally. African American rate 3 times higher than that of whites

Urinary Tract Calculi Nursing Diagnoses and Patient Outcomes

Nursing diagnoses •Impaired urinary elimination •Acute pain •Deficient knowledge •See eCarePlan Outcomes •Relief of pain •No urinary tract obstruction •Knowledge of ways to prevent further recurrence of stones •Impaired urinary elimination related to trauma or obstruction of ureters or urethra •Acute pain related to effects of stone and inadequate pain control or comfort measures •Deficient knowledge related to unfamiliarity with information resources and lack of experience with urinary stones

UTI Older Adult Clinical Manifestations

Older adults? •Characteristic symptoms absent •Non-localized abdominal discomfort •Cognitive impairment •Generalized clinical deterioration •Questionable presence of fever •Can develop...urosepsis UTIs in the elderly are common in both men and women. Although they may have symptoms commonly associated with UTIs, often UTI symptoms in elderly individuals are different. They may show only symptoms of agitation, delirium, confusion and/or behavioral changes. The elderly are at higher risk of developing complications such as kidney infections or sepsis from UTIs. http://www.medicinenet.com/urinary_tract_infection_uti_pictures_slideshow/article.htm Because older adults are less likely to experience a fever with a UTI, the value of body temperature as an indicator of a UTI is unreliable.

Chronic Pancreatitis Clinical Manifestations

Pain ◦Abdominal pain Located in the same areas as in acute pancreatitis Heavy, gnawing feeling; burning and cramplike Not relieved with food or antacids ◦Abdominal tenderness. Pancreatic insufficiency ◦Malabsorption with weight loss ◦Mild jaundice with dark urine ◦Steatorrhea Diabetes mellitus •The patient may have episodes of acute pain, but pain usually is chronic (recurrent attacks at intervals of months or years). •The attacks may become more and more frequent until they are almost constant, or they may diminish as pancreatic fibrosis develops. •Steatorrhea may be large, foul-smelling, fatty stools that float in the toilet water. Takes more than one flushing. Urine and stool may be frothy.

Collaborative Care: Acute Cholecystitis Management

Pain control §NSAIDs §Opioids §Anticholinergics Control infection §Antibiotic treatment §Cholecystostomy Maintenance of F&E balance §NG tube if severe nausea/vomiting §Antiemetics §IV therapy Management is primarily focused on pain control, preventing/controlling infection, and maintaining F & E balance. Treatment is mainly supportive and symptomatic. Pain Control: •The patient with acute cholecystitis or cholelithiasis frequently experiences severe pain. Give the drugs ordered to relieve the pain as required by the patient and before the pain becomes more severe. Nursing comfort measures, such as a clean bed, comfortable positioning, and oral care, are appropriate. NSAIDs (e.g., ketorolac [Toradol]) are given for pain management. Anticholinergics such as atropine and other antispasmodics may be used to relax the smooth muscle and decrease ductal tone. Infection: •A cholecystostomy may be used to drain purulent material from the obstructed gallbladder. Assessment for infections includes monitoring vital signs. A temperature elevation with chills and jaundice may indicate choledocholithiasis. F & E: •If nausea and vomiting are severe, NG tube insertions and gastric decompression may be used to prevent further gallbladder stimulation. Oral hygiene, care of nares, accurate intake and output measurements, and maintenance of suction should be a part of the nursing care plan for this patient. Maintain IV therapy. For patients with less severe nausea and vomiting, antiemetics are usually adequate. When the patient is vomiting, provide comfort measures such as frequent mouth rinses. Remove any vomitus immediately from the patient's view.

Liver Biopsy

Percutaneous procedure uses needle inserted between 6th and 7th or 8th and 9th intercostal spaces on the right side to obtain specimen of hepatic tissue. Often done using ultrasound or CT guidance. Before: check pt's coag status (PTT, clotting or bleeding time). Ensure pt's blood is typed and crossmatched. Take baseline VS. Explain need to hold breath after expiration when needle is inserted. Ensure informed consent has been signed. After: Check VS to detect internal bleeding q15min x 2, q30min x 4, q1hr x 4. Keep pt lying on R side for min 2 hrs to splint puncture site. Keep pt in bed in flat position for 12-14 hrs. Assess pt for complications such as bile peritonitis, shock, pneumothorax. Can also do transjugular liver BX for patients with ascites & bleeding problems.

UTI Health Promotion

Preventative measures •Wipe front to back •Adequate daily fluids •Avoid bladder irritants •Showers preferred •Avoid peri sprays/deodorants •Empty bladder Q 3-4 hrs during day and before and after intercourse. •Evacuate bowel regularly •Cranberry juice or tablets •Report symptoms to health care provider Prevention methods for UTIs have been presented in several preceding slides; here is a short summary of common and easy ways to prevent UTIs: •Wipe from front to back •Adequate daily fluids... For example, a 150-pound person would require 75 oz. each day. Because the person will obtain approximately 20% of this fluid from food, 1800 mL, or just over seven 8-ounce glasses of fluid, would have to be obtained by drinking. Twenty percent of fluid comes from food. Dilutes urine, making bladder less irritable. Flushes out bacteria before they can colonize. •Avoid bladder irritants: Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods •Take showers instead of baths •Don't use feminine hygiene sprays •Urinate regularly every 3-4 hours to flush bacteria out of the urinary tract. Don't "put off" going to the restroom (don't delay urination); Empty bladder before and after intercourse. Temporarily discontinue use of contraceptive diaphragm if have had UTI. •Report symptoms to health care provider The Cranberry Connection Some studies suggest cranberry juice may help prevent UTIs because there is some evidence cranberry juice interferes with E.coli attaching to the bladder wall. Cranberry tablets or capsules may also accomplish this. However, there is no good evidence that indicates cranberries, in any form, can cure a UTI. People with a history of kidney stones should check with their doctor(s) before trying cranberry preparations as a preventive measure against UTIs. http://www.medicinenet.com/urinary_tract_infection_uti_pictures_slideshow/article.htm • It is thought that enzymes found in cranberries inhibit attachment of urinary pathogens (especially E. coli) to the bladder epithelium.

Types of Urinary Calculi

Refer to table...do not need to know specific drugs for each one...just ones used in acute management and general classifications, for example antibiotics used for infection; opioids for acute management of pain...etc. Calcium oxalate: Most common Calcium phosphate: Mixed with struvite or oxalate stones Struvite: Infection...Other important factors in the development of stones include obstruction with urinary stasis and urinary tract infection with urea-splitting bacteria (e.g., Proteus, Klebsiella, Pseudomonas, and some Staphylococcus species). These bacteria cause the urine to become alkaline and contribute to the formation of struvite stones. Uric Acid: Related to diet high in proteins, increase in uric acid Cystine : Cystinuria, an autosomal recessive disorder, is characterized by a marked increased excretion of cystine. Hydrate, potassium citrate to maintain alkaline urine. Renal Staghorn Calculus Associated with infection, 3-4x more common in women. Infected stones, entrapped in the kidney assume a large staghorn configuration as the stone branches to occupy a large portion of the collecting system. Can lead to renal infection, hydronephrosis, and loss of kidney fxn. May need nephrectomy.

Collaborative Care: Open Incision Cholecystectomy

Removal of gallbladder through right subcostal incision T-tube may be inserted into common bile duct §Ensures patency of the duct §Allows excess bile to drain •On selected patients, an incisional (open) cholecystectomy may be performed. •This involves removal of the gallbladder through a right subcostal incision. •A T-tube may be inserted into the common bile duct during surgery when a common bile duct exploration is part of the surgical procedure. •This ensures patency of the duct until the edema produced by the trauma of exploring and probing the duct has subsided. •It also allows the excess bile to drain while the small intestine is adjusting to receiving a continuous flow of bile.

Focus on Postoperative Nephrectomy Nursing Care

Routine SPO care...FOCUS on: •Urine output •Respiratory status •Abdominal distention •With flank incision, may experience muscle aches due to surgical positioning Safety Alert: Never clamp or irrigate the Foley or any other drains unless have a specific order and nursing practice protocols/policies to do so. Urine output: Strict and frequent I & O...expect a normal urine output of at least 0.5 mL/kg/hour With radical nephrectomy usually has Foley...may have NGT; may have nephrostomy tube with partial, and may have other wound drains...identify each and know what to expect from each drain... Measure drainage from the various catheters and record separately. Never clamp or irrigate the Foley or any other drains unless have a specific order and follows protocols/policies for nursing practice. Assess urine for clots, blood, sediment, etc. Can obstruct catheter...notify surgeon for issues. Respiratory Status: If has a flank incision, patient may be reluctant to T,C, and DB because of pain. Give pain meds to ensure that patient is comfortable and can perform these exercises. Use IS, etc. and start early and frequent ambulation. Abdominal Distention: Frequently due to paralytic ileus after surgery on ureters and kidneys. Secondary to manipulation and compression of the gut during surgery. May be NPO for first 24-48 hours after surgery and will receive IV fluids until patient taking po. Will progress to regular diet. Immediately after your operation You may wake up in intensive care or a high dependency recovery unit. These are places where you can have one to one nursing care. And your surgeon and anaesthetist can keep a close eye on your progress. As soon as your doctors are sure you are recovering well, you will be moved back to the ward. When you wake up, you will have several different tubes in place. This can be a bit frightening. But it helps to know what they are all for. You will have Drips (intravenous infusions) to give you blood transfusions, and fluids until you are drinking again One or more drains coming out of your back or side, near your wound - the drains stop blood and tissue fluid collecting around the operation site A tube down your nose into your stomach (nasogastric tube) to drain fluid and stop you feeling sick A tube into your bladder (catheter) so that your urine output can be measured If you have had part of a kidney removed, you will have another drainage tube from the wound site. This is to collect urine, and stop it leaking into the wound. Your nurse will check this bag and measure the contents frequently. You will have a blood pressure cuff on your arm when you first wake up. And you will also have a little clip on your finger (called a pulse oximeter) to measure your pulse and the oxygen levels in your blood. You may also have an oxygen mask on for a while. Your nurse will check your blood pressure often for the first few hours after you come round from the anaesthetic. Your urine output will be monitored very closely, at least once an hour at first.

Peritoneal Dialysis Procedure

The process of doing PD is called an exchange. A patient using PD generally completes four to six exchanges every day. Blood never leaves the body during PD. day. Dialysis fluid enters your peritoneal cavity (called "Fill" or Inflow). While the fluid is in your peritoneal cavity, extra fluid and waste travel across the peritoneal membrane into the dialysis fluid (called "Dwell"). After a few hours, the dialysis fluid is drained (called "Drain") and replaced with new fluid.

Focus on Transurethral Resection of Prostate (TURP)

Transurethral Resection (TURP) Removal of obstructing prostate tissue using resectoscope inserted through urethra Outcome for 80% to 90% is excellent. Relatively low risk Performed under spinal or general anesthesia and requires hospital stay •TURP has long been considered the "gold standard" surgical treatment for obstructing BPH. Although this procedure remains the most common operation performed, the number of TURP procedures done in recent years has decreased because of the development of less invasive technologies. •A resectoscope is inserted through the urethra to excise and cauterize obstructing prostatic tissue. •A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage.

Benign Prostatic Hyperplasia (BPH)Collaborative Care

Treatment is generally not based on the size of the prostate. •Dietary changes (decreasing intake of caffeine and artificial sweeteners, limiting spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may result in improvement of symptoms. •A timed voiding schedule may reduce or eliminate symptoms, thus negating the need for further intervention. If the patient begins to have signs or symptoms that indicate an increase in obstruction, further treatment is indicated. Instruct patient with obstructive symptoms to urinate every 2 to 3 hours and when first feeling urge. •Teach need for adequate fluid intake. Restricting fluids increases chance of infection. The patient may believe that if he restricts his fluid intake, symptoms will be less severe, but this only increases the chance of an infection. However, if the patient increases his intake too rapidly, bladder distention can develop as a result of the prostatic obstruction. •Offers symptomatic relief of BPH 5α-Reductase inhibitors Example: finasteride (Proscar), dutasteride (Avodart), Jalyn (finasteride + tamsulosin) ↓ Size of prostate gland Takes 3 to 6 months for improvement Side effects: decreased libido, decreased volume of ejaculation, ED •Alternatives to surgical intervention for some patients now include drug therapy and minimally invasive procedures. •Drugs include 5α-reductase inhibitors and α-adrenergic receptor blockers. Combination therapy using both types of these drugs has been shown to be more effective in reducing symptoms than using one drug alone. •Finasteride is an appropriate treatment option for individuals who have moderate to severe symptom scores on the AUA symptom index. •The drug must be taken on a continuous basis to maintain therapeutic results. •Serum PSA levels are decreased by almost 50% when taking finasteride. •Therefore PSA levels should be doubled when comparing the patient's current levels to pre-medication levels. 5α-Reductase inhibitors May lower the risk of prostate cancer Not recommended in the prevention of prostate cancer due to an increased risk of developing an aggressive form of prostate cancer •Patients with an increased PSA level while taking these medications should be referred to their health care provider. •The need for regular prostate cancer screening should also be discussed with the provider. •α-Adrenergic receptor blockers Examples: tamsulosin (Flomax), doxazosin (Cardura), silodosin (Rapaflo) Promotes smooth muscle relaxation in prostate, facilitates urinary flow Improvement in 2 to 3 weeks Offer symptomatic relief but do not treat hyperplasia Although α-adrenergic blockers are more commonly used for treatment of hypertension, these drugs promote smooth muscle relaxation in the prostate. Erectogenic Drugs Tadalifil (Cialis) effectively reduces symptoms of both BPH and ED. Herbal Therapy Successfulness varies. Use should be revealed to health care provider. •Erectile dysfunction is further discussed later in the chapter. •Herbal extracts have been used in the management of lower urinary symptoms associated with BPH. •Plant extracts such as saw palmetto (Serenoa repens) are taken by some patients. •However, research indicates that saw palmetto has no benefit over a placebo. •In a limited number of small trials, herbal preparations such as saxifrage, beta-sitosterol, Pygeum africanum, and Cernilton have shown some success in reducing the symptoms of BPH.

Acute Pancreatitis Complications

Two significant local complications Pseudocyst ◦Cavity outside of pancreas filled with necrotic products & liquid secretions ◦S & S: Abd. pain ◦Treatment Abscess ◦Large fluid filled cavity within pancreas secondary to necrosis that may perforate into other organs ◦S & S: Abd. pain, abd. mass, fever, leukocytosis ◦Treatment •A pancreatic pseudocyst is an accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall. •Manifestations of pseudocyst are abdominal pain, palpable epigastric mass, nausea, vomiting, and anorexia. •The serum amylase level frequently remains elevated. CT, MRI, and endoscopic ultrasonography (EUS) may be used in the detection of a pseudocyst. •The cysts usually resolve spontaneously within a few weeks but may perforate, causing peritonitis, or rupture into the stomach or duodenum. •Treatment options include surgical drainage procedure, percutaneous catheter placement and drainage, and endoscopic drainage. •A pancreatic abscess is a collection of pus. •It results from extensive necrosis in the pancreas. •It may become infected or perforate into adjacent organs. •Manifestations of an abscess include upper abdominal pain, abdominal mass, high fever, and leukocytosis. •Pancreatic abscesses necessitate prompt surgical drainage to prevent sepsis.

Classification of UTI

Uncomplicated •Occurs in otherwise normal urinary tract •Usually involves only the bladder Complicated Coexists with presence of: •Obstruction •Stones •Catheters •Diabetes/neurologic disease •Pregnancy-induced changes •Recurrent infection The individual with a complicated infection is at risk for pyelonephritis, urosepsis, and renal damage.

Diagnostic Studies Acute Pyelonephritis

Urinalysis •Pyuria •Bacteriuria •Hematuria •WBC' Casts •Complete blood count (CBC) --Leukocytosis •Urine culture and sensitivity •CBC with diff •Blood cultures •Imaging studies •Urinalysis results indicate pyuria, bacteriuria, and varying degrees of hematuria. • WBC casts may be found in the urine, indicating involvement of the renal parenchyma. • A complete blood cell count will show leukocytosis and a shift to the left with an increase in immature neutrophils (bands). •Ultrasonography of the urinary system may be performed to identify anatomic abnormalities, hydronephrosis, renal abscesses, or the presence of an obstructing stone. • CT urography is also used to assess for signs of infection in the kidney and complications of pyelonephritis, such as impaired renal function, scarring, chronic pyelonephritis, or abscesses. Image; Cortical surface shows grayish white areas of inflammation and abscess formation (arrow).

UTI Diagnostic Studies

Urinalysis (UA) •Turbid, cloudy, sediment or tinged red •+ leukoesterase (WBC's), nitrites (bacteria) •Clean specimen container •Will be referring to a number of assessment abnormalities, urinary system diagnostic studies while reviewing GU-Renal disorders...these are presented well in table format in textbook. •In a patient suspected of having a UTI, initially conduct dipstick urinalysis to identify the presence of nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs that indicates pyuria). • These findings can be confirmed by microscopic urinalysis. Nitrites indicate bacteriuria Leukocyte esterase=enzyme present in WBC's indicating pyuria Bacterial counts of 105 colony-forming units per milliliter (CFU/mL) or higher typically indicate a clinically significant UTI. However, counts as low as 102 to 103 CFU/mL in a person with signs and symptoms are indicative of UTI.

UTI Drug Therapy

Urinary Analgesics •Phenazopyridine (Pyridium) •Red/Orange urine/stains •Hemolytic anemia •Methenamine/phenyl salicylate (Urised ) •Blue or green urine fen az oh peer' i deen Phenazopyridine (Pyridium) •Used in combination with antibiotics •Provides soothing effect on urinary tract mucosa •Stains urine reddish orange •Can be mistaken for blood and may stain underclothing •Although this drug is typically effective in relieving the transient acute discomfort associated with a UTI, the nurse should advise patients to avoid long-term use of phenazopyridine because it can produce hemolytic anemia meh THEH na meen Methenamine/phenyl salicylate (Urised) sa-lis-sa-late •Used in combination with antibiotics •Used to relieve UTI symptoms •Preparations with methylene blue tint urine blue or green U R I S E D™ is a dark blue, round, tablet for oral administration. It is a combination of antiseptics (Methenamine, Methylene Blue, Phenyl Salicylate, Benzoic Acid) and parasympatholytics (Atropine Sulfate, Hyoscyamine). Each tablet contains: Methenamine 40.8 mg, Phenyl Salicylate 18.1 mg, Methylene Blue 5.4 mg, Benzoic Acid 4.5 mg, Atropine Sulfate 0.03 mg and Hyoscyamine (as the sulfate) 0.03 mg. Information for Patients: You should avoid using drugs and/or foods that produce alkaline urine while taking this medicine. If you are taking any anti-infective medications containing a sulfonamide, check with your doctor before using U R I S E D™. While taking this medicine, your urine may become blue to blue-green and the feces may be discolored as a result of excretion of Methylene Blue, so care should be taken to avoid staining clothing or other items. To avoid Methylene Blue stains on skin, mouth or teeth, make sure your hands are dry and that the tablets are swallowed quickly with liberal fluid intake.

UTI Health Promotion: Following a CAUTI Bundle of Care

Urinary Tract Obstruction Neurogenic Bladder Dysfunction Urologic Studies or Procedures Stage III or IV Pressure Ulcer with Incontinent Patient Hospice-Palliative Care Risk of Local Wound Contamination with Incontinent Patient Surgery (needs order to continue in postoperative period) Image: right lower corner...Chart Audit...focus on nursing care... The primary goals of CAUTI Bundles are to to implement Foley catheter practices based on current national (for example, CDC) Guidelines and best practices. It is important to embed an electronic infrastructure that would drive and sustain these care practices. Prevent nosocomial infections Avoid unnecessary catheterizations/remove early (Most important!) Aseptic technique must be followed during instrumentation procedures Wash hands before and after contact Wear gloves for care of urinary system Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals

Urinary Tract Calculi: Etiology and Pathophysiology

Various theories of stone formation •Supersaturation: crystals precipitate & form a stone •Mucoprotein: forms matrix of stone •Urine pH, solute load and inhibitors can affect the formation of a stone. --inc pH--> less soluble are calcium & phosphate --dec pH--> less soluble are UA & cystine •When a substance is not very soluble in fluid, it is more likely to precipitate out of solution. Keep urine dilute and free flowing •The higher the pH (alkaline), the less soluble are calcium and phosphate. •The lower the pH (acidic), the less soluble are uric acid and cystine. •Some patients may be taught to self-monitor urinary pH, or they may be asked to measure urinary output. •Stones can obstruct flow of urine •May develop hydroureter and hydronephrosis •Stasis of urine may cause UTI Vesicouireteral reflex: backflow of urine from the lower to upper urinary tract Hydroureter: dilation of the renal pelvis Hydronephrosis: dilation or enlargement of the renal pelvises and calyces

Stages of Chronic Kidney Disease

§Up to 80% of GFR may be lost without much change in functioning of body §Remaining nephrons hypertrophy to compensate §End result is a systemic disease involving every organ §See Table 46-6 (2017) §See Table 46-8 for indicators of kidney function

Esophagogastroduodenoscopy (EGD) (Endoscopy)

passage of a fiberoptic tube through the mouth and throat into the digestive tract for visualization of the esophagus, stomach, and small intestine; biopsies can be performed Sclerose varices

AKI Gerontologic Considerations

polypharmacy hypotension diuretic therapy aminoglycoside therapy obstructive disorders surgery infection

Acute Pancreatitis Additional Nursing Implementations

}Acute intervention (cont'd) ◦Electrolyte balance Blood glucose monitoring (hyperglycemia) Monitoring for signs of hypocalcemia Tetany (jerking, irritability, twitching) Numbness around lips/fingers Positive Chvostek's or Trousseau's sign Monitoring for hypomagnesemia, hypokalemia, hyponatremia, hypochloridemia •Hyperglycemia is a potential complication. Check BG often and treat prn. May need TPN which can aggravate the hyperglycemia and increase insulin requirements even more. •Frequent vomiting, along with gastric suction, may result in decreased chloride, sodium, and potassium levels. •Calcium gluconate (as ordered) should be given to treat symptomatic hypocalcemia. •Give magnesium prn.

Hepatitis Clinical Manifestations

¢Jaundice Results when bilirubin diffuses into tissues ¢Urine darkens because excess bilirubin is excreted. ¢If bilirubin cannot flow out of liver, stool will be light or clay-colored. ¢Pruritus can accompany jaundice. §Accumulation of bile salts beneath the skin ¢When jaundice occurs, fever subsides. ¢Liver is usually enlarged and tender.

Hepatitis Complications

¢Most patients with acute viral hepatitis recover completely with no complications. ¢Overall mortality rate <1% ¢Fulminant hepatic failure ¢Chronic hepatitis ¢Cirrhosis ¢Hepatocellular carcinoma

Nursing Care for AV Fistulas & Grafts

§AV fistulas and grafts have a high risk of developing clots and infection §Avoid BP and venipuncture on affected limb §Palpate "thrill" at anastomosis site--this and hearing a bruit are expected findings. §Monitor for circulation distal to site

Cholelithiasis etiology and pathophysiology

§Composition of stones: cholesterol, bile salts, and calcium in solution §Bile in the GB is supersaturated with cholesterol (lithogenic) §Followed by precipitation of cholesterol §Precipitate serves as a nucleus for more cholesterol to adhere to increasing size of stone §Stasis or hypomotility of GB leads to progression of supersaturation (biliary sludge & stones) •Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered so that precipitation of these substances occurs. •In patients with cholelithiasis, the bile secreted by the liver is supersaturated with cholesterol (lithogenic bile). The bile in the gallbladder also becomes supersaturated with cholesterol. When bile is supersaturated with cholesterol, precipitation of cholesterol occurs. The precipitate serves as a nucleus for other substances (including more cholesterol) to adhere to; increasing the size of the stone. •Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, and protein. Mixed cholesterol stones, which are predominantly cholesterol, are the most common gallstones. •The changes in the composition of bile are probably significant in the formation of gallstones. Stasis of bile (hypomotility of the GB) leads to progression of the supersaturation and changes in the chemical composition of the bile (biliary sludge) •Image: The three principal phases responsible for the formation of cholesterol gallstones illustrated with a Venn diagram. •Going back to case study risk factors: Immobility, pregnancy, and inflammatory or obstructive lesions of the biliary system decrease bile flow. Hormonal factors during pregnancy may cause delayed emptying of the gallbladder, resulting in stasis of bile. •The cause of gallstones is unknown. Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered so that these substances precipitate. Conditions that upset this balance include infection and disturbances in the metabolism of cholesterol. In patients with cholelithiasis, the bile secreted by the liver is supersaturated with cholesterol (lithogenic bile). The bile in the gallbladder also becomes supersaturated with cholesterol. When bile is supersaturated with cholesterol, precipitation of cholesterol occurs in the gallbladder. •Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, and protein. Mixed cholesterol stones, which are predominantly cholesterol, are the most common gallstones. •Changes in the composition of bile are significant in the formation of gallstones. Stasis of bile leads to progression of the supersaturation and changes in the chemical composition of the bile (biliary sludge). Immobility, pregnancy, and inflammatory or obstructive lesions of the biliary system decrease bile flow. Hormonal factors during pregnancy may cause delayed emptying of the gallbladder, resulting in stasis of bile.

Acute Kidney Injury Diagnostic Studies

§Diagnostic studies §Thorough history §Serum creatinine §Urinalysis §Kidney ultrasonography §Renal scan §Computed tomography (CT) scan §Renal biopsy ALERT: In patients with kidney failure, contrast-induced nephropathy (CIN) can occur when contrast medium for diagnostic studies causes nephrotoxic injury.

Ambulatory and Home Care: Open Incision Cholecystectomy

§Discharged in 2-3 days §No heavy lifting for 4-6 weeks §Usual activities when feeling ready §May need low-fat diet for 4-6 weeks §Weight reduction program if needed •After an incisional cholecystectomy --Instruct the patient to avoid heavy lifting for 4 to 6 weeks. --Usual sexual activities, including intercourse, can be resumed as soon as the patient feels ready unless given other instructions by the HCP. •Sometimes the patient is required to remain on a low-fat diet for 4 to 6 weeks. If so, an individualized dietary teaching plan is necessary. A weight-reduction program may be helpful if the patient is overweight. Most patients tolerate a regular diet with no difficulties but should avoid excessive fats.

Assessment/Care of Acute Kidney Injury

§Endocrine or Internal Secretion §AKI/CKD anemic Target Hgb = no more than 10-12 g/dL. Give iron & FA supplements. §Kidneys normally activate Vitamin D §What happens in AKI/CKD? §See CKD-MBD handout for management.

Acute Kidney Injury - Nursing Diagnoses

§Excess fluid volume §Risk for infection §Fatigue §Anxiety §Potential complication: dysrhythmia

Complications of Peritoneal Dialysis

§Exit site infection §Peritonitis §Hernias §Lower back problems §Bleeding §Pulmonary complications §Protein loss

Collaborative Care:General Drug Therapy with Obstruction and Chronic GB Disease

§Fat-soluble vitamins (A, D, E, K) may need to be given §Bile salts: facilitates digestion and vitamin absorption Cholestyramine (Questran) may be given for pruritus §Given in powdered form, mixed with milk or juice §Monitor for side effects (nausea/vomiting, diarrhea or constipation, skin reactions) •If the patient has chronic gallbladder disease or any biliary tract obstruction, in addition to bleeding precautions, fat-soluble vitamins (A, D, E, and K) may need to be given. Bile salts may be administered to facilitate digestion and vitamin absorption. •For treatment of pruritus, in addition to comfort measures already described, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is administered in powder form and should be mixed with milk or juice. Side effects include nausea, vomiting, diarrhea or constipation, and skin reactions. Because cholestyramine may bind with other medications, check drug- to- drug interactions prior to administering.

Ambulatory and Home Care: Laparoscopic Cholecystectomy

§Focus on Ineffective Health Management §Monitor for complications: infection, bile leak, signs of injury to CBD: severe abd pain, N/V, fever, chills §Liquids first day; Light meals for a few days §Remove bandages the day after surgery and then can shower §When to notify surgeon §Gradually resume activities §Return to work in 1 week §May need low-fat diet for several weeks Include the following instructions in the patient's postoperative teaching plan. •After a laparoscopic cholecystectomy, instruct the patient to have liquids for the rest of the day and eat light meals for a few dayThe amount of fat in the postoperative diet depends on the patient's tolerance of fat. A low-fat diet may be helpful if the flow of bile is reduced (usually only in the early postoperative period) or if the patient is overweight. Sometimes the patient is instructed to restrict fats for 4 to 6 weeks.s. Otherwise, no special dietary instructions are needed other than to eat nutritious meals and avoid excessive fat intake. Remove the bandages on the puncture site the day after surgery, and then you can shower. Notify your surgeon if any of the following signs and symptoms occur: •Redness, swelling, bile-colored drainage or pus from any incision •Severe abdominal pain, nausea, vomiting, fever, chills You can gradually resume normal activities. You can return to work within 1 week of surgery. You can resume your usual diet, but a low-fat diet is usually better tolerated for several weeks following surgery.

Biliary Tract Physiology

§Function: store & concentrate bile from liver §Cholecystokinin: hormone in duodenal mucosa secreted with fatty foods and amino acids in small intestine §Contracts GB & relaxes sphincter of Oddi to empty bile into CBD and duodenum §Bile moves into intestine by contraction of GB & relaxation of sphincter of Oddi §Emulsification of fats and aids in absorption of fats and fat-soluble vitamins (A,D, E, K) Holds 50 mL of bile & secretes 1000 mL/daily

Assessment/Care of Acute Kidney Injury - RECOVERY PHASE

§GFR returns to normal §Can take up to a year §Residual renal insufficiency very common §Some patients will progress to chronic renal failure

Biliary Tract Anatomy

§Gall Bladder: Pear shaped, distensible, muscular organ located on underside of liver (RUQ) §Cystic duct joins GB to common bile duct (CBD) The biliary tract consists of the gallbladder and ducts that connect the liver, gallbladder, and duodenum. The gallbladder is a pear-shaped sac located below the liver. The gallbladder's function is to concentrate and store bile. It holds approximately 45 mL of bile. The presence of fat in the upper duodenum triggers the release of cholecystokinin, which causes the gallbladder to contract and release bile. The hepatic ducts receive bile from the canaliculi in the liver lobules. The left and right hepatic ducts merge with the cystic duct from the gallbladder to form the common bile duct. Bile moves down the common bile duct to enter the duodenum at the ampulla of Vater (Fig. 38-3). The pancreatic duct also enters the duodenum at this point.

Complications of Cholecystitis

§Gangrenous cholecystitis §Subphrenic abscess §Pancreatitis §Cholangitis §Biliary cirrhosis §Fistulas §Gallbladder rupture → peritonitis §Choledocholithiasis •Complications of cholelithiasis and cholecystitis include gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis. •In older patients and those with diabetes, gangrenous cholecystitis and bile peritonitis are the most common complications of cholecystitis. •Choledocholithiasis (stone in the common bile duct) may occur, producing symptoms of obstruction.

VIRAL HEPATITIS ETIOLOGY AND RISK FACTORS

•Hepatitis A (HAV) -Fecal-oral route -Crowding, poor sanitation -No chronic carrier state •Hepatitis B (HBV) -Blood, saliva, semen -Health care workers, sexual activity, IV drug users -Perinatally -More infectious than HIV •Hepatitis C (HCV) -Blood, IV drug use -Risks similar to hep B •Hepatitis D (HDV) -Blood -IV drug users, sexual activity -Risks similar to hep B •Hepatitis E (HEV) -Fecal/oral route -Food or water -Similar to hep A -Not common in US

Immediate Postoperative Care: Open Incision Cholecystectomy

§General SPO Care §PAIN Control Essential: Maintain adequate ventilation & Prevent respiratory complications §General postoperative nursing care §Maintain drainage tubes (T-tube, Penrose tube, or Jackson-Pratt tube), if present §Liquids to regular diet after return of bowel sounds •Postoperative nursing care for incisional cholecystectomy focuses on adequate ventilation and prevention of respiratory complications. •Other nursing care is the same as general postoperative nursing care. •If the patient has a T-tube, you need to maintain bile drainage and monitor T-tube function and drainage. The T-tube is usually connected to a closed gravity drainage system. If the Penrose or Jackson-Pratt tube or the T-tube is draining large amounts of bile, it is helpful to use a sterile pouching system to protect the skin. •Encourage the patient to replace fluids and electrolytes that are lost. •If an incisional cholecystectomy is done, the patient will progress from liquids to a regular diet once bowel sounds have returned.

Cholecystitis Etiology and Pathophysiology

§Most commonly associated with obstruction from stones or sludge (acalculous) §Inflammation (Major finding) •Cholecystitis is most commonly associated with obstruction caused by gallstones or biliary sludge. Cholecystitis in the absence of obstruction (acalculous cholecystitis) occurs most frequently in older adults and in patients who are critically ill. Acalculous cholecystitis is also associated with prolonged immobility and fasting, prolonged parenteral nutrition, and diabetes mellitus. The main cause of this illness is thought to be bile stasis. Critically ill patients are more predisposed because of increased bile viscosity due to fever and dehydration and because of prolonged absence of oral feeding resulting in a decrease or absence of cholecystokinin-induced gallbladder contraction. Other etiologic factors include adhesions, neoplasms, anesthesia, and opioids. •Once acalculous cholecystitis is established, secondary infection with enteric pathogens, including Escherichia coli, Enterococcus faecalis, Klebsiella, Pseudomonas, and Proteus, is common. Perforation occurs in severe cases. •Inflammation is the major pathophysiologic condition and may be confined to the mucous lining or involve the entire wall of the gallbladder. During an acute attack of cholecystitis, the gallbladder is edematous and hyperemic, and it may be distended with bile or pus. The cystic duct is also involved and may become occluded. The wall of the gallbladder becomes scarred after an acute attack. Decreased functioning will occur if large amounts of tissue become fibrotic.

Terminology

§OLIGURIA: 100-400mL/day §ANURIA: < 100 mL/day §AZOTEMIA: ↑ BUN and Creatinine in blood; approximately 75% of nephrons non-functional §UREMIA: Toxic syndrome in which GFR <10 mL/min); symptoms manifest in multiple body systems r/t accumulation of waste products

Dialysis Procedure

§Predialysis §Initiation of Dialysis §Monitoring During Dialysis §Discontinuing Dialysis

Overall Goals for Management of Patient with Gallbladder Disease

§Relief of pain and discomfort §No complications postoperatively §No recurrent attacks of cholecystitis or cholelithiasis The overall goals are that the patient with gallbladder disease will have (1) relief of pain and discomfort, (2) no complications postoperatively, and (3) no recurrent attacks of cholecystitis or cholelithiasis.

Nursing Implementation - Hepatitis Acute intervention

§Rest §Jaundice ¢Assessment of degree of jaundice ¢Small, frequent meals

Staging of AKI: RIFLE

§Risk §Injury §Failure §Loss §End-Stage (See Table 46-3)

Nursing Management of Patient with AKI/CKD

§See 46-1 eCarePlan in WorldClass §Major nursing diagnoses (+ many more!!!) §Excess Fluid Volume §Risk for Injury §Imbalanced Nutrition §Grieving §Patient & Caregiver Teaching Plan Table 46-12

Case Study: Patient with AKI Current Serum Labs Mr. S. has developed oliguria with the following serum lab results. Interpret each lab and explain significance.

§Sodium 142 mEq/L §Chloride 110 mEq/L §Potassium 6.0 mEq/L §CO2=12mEq/L §BUN 110 mg/dL §Creatinine 12 mg/dL §Uric Acid 16.2 mg/dL §Glucose 150 mg/dL §Magnesium 4.1 mg/dL §Phosphorus 7.0mg/dL §Albumin 2.3 mg/dL §Total Calcium 6.5 mg/dL §Ionized Calcium 0.8 mmol/L §Hct 20% §Hgb 6 g/dL §WBC 14,000 §Platelets 62,000 §Arterial blood gases= 7.25, O2=56, pCO2=22, HCO3=11; BE=-15; SaO2= 87 ( FiO2 = 2 LPM NC) §UA=many cast cells

Cholelithiasis etiology and pathophysiology - 2

§Stones may remain in gallbladder or may migrate to cystic or common bile duct (Choledocholithiasis) kō-led′ō-kō-lith-ī′ă-sis §Cause pain as they pass through ducts §May lodge in ducts and produce an obstruction •The stones may remain in the gallbladder or migrate to the cystic duct or to the common bile duct. They cause pain as they pass through the ducts, and they may lodge in the ducts and produce an obstruction. Small stones are more likely to move into a duct and cause obstruction. If the blockage occurs in the cystic duct, the bile can continue to flow into the duodenum directly from the liver. However, when the bile in the gallbladder cannot escape, this stasis of bile may lead to cholecystitis. Will see a variety of clinical manifestation if CBD is obstructed...will discuss soon.

Collaborative Care: Laparoscopic Cholecystectomy

§Treatment of choice §Removal of gallbladder through one to four puncture holes §Minimal postoperative pain §Few complications •Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. •Approximately 90% of cholecystectomies are done laparoscopically. •In this procedure, the gallbladder is removed through one to four small punctures in the abdomen. •The surgeon makes a small cut below the umbilicus and inserts a needle into the area. •Carbon dioxide gas is passed into the abdomen to expand the area, which allows the surgeon to see the organs more clearly and provides more room to work. •A laparoscope, which has a camera attached, is inserted into the abdomen. (The incision sites may vary.) These punctures are used for insertion of the laparoscope and the grasping forceps. Using closed-circuit monitors to view the abdominal cavity, the surgeon retracts and dissects the gallbladder and removes it with grasping forceps. This is a safe and routine procedure with minimal morbidity and quick recovery time. •Most patients have minimal postoperative pain and are discharged the day of surgery or the day after. They are usually able to resume normal activities and return to work within 1 week. •The main complication is injury to the common bile duct. The few contraindications to laparoscopic cholecystectomy include peritonitis, cholangitis, gangrene or perforation of the gallbladder, portal hypertension, and serious bleeding disorders.

Clinical Manifestations: Acute Cholecystitis: Pain

§Vary from severe to none at all §With acute attack, pain more severe when stones moving or obstructing §Spasms may result (biliary colic) §Often steady, excruciating §May be referred to shoulder/scapula (right) §Severe pain may last an hour with residual tenderness in RUQ and may have abdominal rigidity §Occurs 3-6 hours after high-fat meal or when patient lies down •The severity of symptoms depends on whether the stones are stationary or mobile and whether obstruction is present. •When a stone is lodged in the ducts or when stones are moving through the ducts, spasms may result. •The gallbladder spasms occur in response to the stone. •This sometimes produces severe pain, which is termed biliary colic even though the pain is rarely colicky. •The pain is more often steady. •The pain can be excruciating and accompanied by tachycardia, diaphoresis, and prostration. •The pain may be referred to the right shoulder and scapula. •The severe pain may last up to an hour, and when it subsides, there is residual tenderness in the right upper quadrant. Physical findings include right upper quadrant tenderness and abdominal rigidity. •The attacks of pain frequently occur 3 to 6 hours after a high-fat meal or when the patient lies down. •Differential to rule out MI

VIRAL HEPATITIS PREVENTION - C, D, & E

•Hepatitis C -Transmission similar to hepatitis B -Same measures helpful in prevention -Active immunization •No vaccine -Passive immunization •Immune globulin after exposure •Not recommended for prophylaxis •Hepatitis D -Coexists with hepatitis B -Hepatitis B vaccine -Same precautions as hepatitis B •Hepatitis E -Personal hygiene and sanitation

Urinary Tract Calculi Clinical Manifestations

•"Kidney stone dance" •Pain moves to lower quadrant of abdomen as stone nears UVJ •Testicular versus labial pain •Both sexes experience groin pain •UTI symptoms & hematuria •Mild shock with cool, moist skin •N & V -Severe pain •The first symptom of a kidney stone is usually severe pain in the flank area, back, or lower abdomen that begins suddenly. •Renal colic is the term used for the sharp, severe pain, which results from the stretching, dilation, and spasm of the ureter in response to the obstructing stone. Renal colic is due to an increase in ureteral peristalsis in response to the passage of small stones along the inner lumen of the ureter. Patients with renal colic have a hard time being still. They go from walking to sitting to lying down, and then they repeat the process. Some people refer to this as the kidney stone dance. •Men may experience testicular pain, whereas women may complain of labial pain. Both men and women may experience pain in the groin. May be no pain without an obstruction Kidney: Abdominal or flank pain (usually severe) Ureteral passage: Intense and colicky, radiates to genitalia and thigh •The patient may have concomitant manifestations of urinary infection with dysuria, fever, and chills. What are symptoms of kidney stones? Many kidney stones are painless until they travel from the kidney, down the ureter, and into the bladder. Depending on the size of the stone, movement of the stone through the urinary tract can cause severe pain with sudden onset. People who have kidney stones often describe the pain as excruciating. The lower back, abdomen, and sides are frequent sites of pain and cramping. Those who have kidney stones may see blood in their urine. Fever and chills are present when there is an infection. Seek prompt medical treatment in the event of these symptoms. http://www.medicinenet.com/kidney_stone_pictures_slideshow/article.htm Encourage ambulation to promote movement of the stone from the upper to the lower urinary tract.

Bladder Cancer

•73,000 new cases per year; 3x more males than females; ages 60-70; •Transitional cell carcinomas Risk factors •Cigarette smoking , dye exposure, chronic abuse of phenacetin-containing analgesics + others Types of Bladder Cancer Bladder cancers are named for the specific type of cell that becomes cancerous. Most bladder cancers are transitional cell carcinomas, named for the cells that line the bladder. Other less common types of bladder cancer are squamous cell carcinoma and adenocarcinoma. Top Image: This bladder was removed surgically from a male who had a long history of smoking. He had presented with hematuria. The opened bladder reveals masses of a neoplasm that histologically proved to be urothelial carcinoma (previously known as a transitional cell carcinoma). Urothelial carcinoma can arise anywhere in the urothelium lining the urinary tract from the urethra to the calyces, but is most common in bladder. http://library.med.utah.edu/WebPath/RENAHTML/BLAD060.html Stages of Bladder Cancer The stage of a cancer is the extent to which it has spread. Bladder cancers are staged as follows:Stage 0: Cancerous cells in the inner lining tissue of the bladder.Stage I: Tumor has spread to the bladder wall.Stage II: Tumor has penetrated the inner wall and is present in muscle of the bladder wall. Stage III: Tumor has spread through the bladder to fat around the bladder. Stage IV: Tumor has spread to the wall of the pelvis or abdomen, to the lymph nodes, or to areas away from the bladder such as the lungs, liver, or bones.

GI Bleed & Esophageal Varices

•A major complication of liver disease and potentially a life-threatening emergency (BLEEDING) •The small vasculature in the esophagus is filled with high pressure from portal hypertension •The small friable veins in the esophagus swell and are prone to rupture •The patients presents with vomiting of bright red blood.

BPH Nursing Diagnoses and Patient Outcomes

•Acute Pain •Impaired urinary elimination •Risk for Infection •Knowledge deficit •Sexual dysfunction •Expected outcomes after BPH surgery -Report satisfactory pain control. -Report improved urinary function with no pain or incontinence. Pre-op care: Restore urinary drainage prior to surgery. Coude Catheter-use lidocaine gel prior to insertion. Antibiotics. Education re: sexual dysfunction Post-op care: 3 way catheter,

Nutritional Therapy for liver disease

•High calories with high carbohydrates (to prevent hypoglycemia & catabolism) and moderate to low levels of fat •? Protein restriction with hepatic encephalopathy; ETOH cirrhosis patient may have protein-calorie malnutrition (PCM) •Low sodium with ascites & edema •B-complex vitamins •Consult a nutritionist to help manage

Acute Pancreatitis Nursing Diagnoses

•Acute pain •Deficient fluid volume •Imbalanced nutrition: less than body requirements •Ineffective self-health management •Refer to eCarePlan Nursing diagnoses for the patient with acute pancreatitis may include, but are not limited to, the following: • Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort measures • Deficient fluid volume related to nausea, vomiting, restricted oral intake, and fluid shift into the retroperitoneal space • Imbalanced nutrition: less than body requirements related to anorexia, dietary restrictions, nausea, loss of nutrients from vomiting, and impaired digestion • Ineffective self-health management related to lack of knowledge of preventive measures, diet restrictions, alcohol restriction intake, and follow-up care

Benign Prostatic Hyperplasia (BPH)Complications

•Acute urinary retention •UTI •Sepsis secondary to UTI •Bladder calculi •Hydronephrosis & renal failure •Pyelonephritis Related to urinary obstruction Relatively uncommon in BPH Acute urinary retention Complication with sudden, painful inability to urinate Treatment involves catheter insertion and possible surgery. UTI and sepsis Incomplete bladder emptying with residual urine provides medium for bacterial growth.Incomplete bladder emptying is associated with partial obstruction. Calculi may develop in bladder because of alkalinization of residual urine. Bladder stones are more common in men with BPH, although the risk of renal calculi is not significantly increased. Renal failure Caused by hydronephrosis. Hydronephrosis is a distention of pelvis and calyces of kidney by urine that cannot flow through the ureter to the bladder. Pyelonephritis Bladder damage Acute urinary retention: catherization UTI: Incomplete emptying provides environment favorable for bacterial growth Calculi: develop due to alkaline residual urine (bladder more common)

TURP: SPO: Continuous Bladder Irrigation (CBI)

•Adjust CBI (0.9% saline) to keep urine pink, free flowing & free of clots (Bleeding causes Bright Red urine) •Keep accurate I & O •Manual irrigation prn with saline per MD order (Aseptic) •See Teamwork & Collaboration for Patient Receiving Bladder Irrigation (p. 1274) •Monitor Hct & VS for signs of bleeding •30 ml balloon used to tampanode surgical site •Patient has urge to void because of large balloon •Traction applied to catheter...do not release Bladder spasms •R/O blood clot •Give medication to control •Urine leakage around meatus could be indicator of catheter blockage from clot or kink Bladder spasms: B&O suppository (Belladonna and opium); Oxybutin (Ditropan); Relaxation techniques Infection •May be on antibiotics •Strict aseptic technique •Stool softeners to avoid straining and ↑ bleeding Straining increases intra-abdominal pressure, which can lead to bleeding at the operative site. A diet high in fiber facilitates the passage of stool. Post-op care...manage CBI with 3 way Foley •The bladder is irrigated either manually on an intermittent basis or more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution. •Use careful aseptic technique when irrigating the bladder because bacteria can easily be introduced into the urinary tract.

Hepatic Encephalopathy (HE)

•Ammonia accumulates in the liver and is not converted to urea •The ammonia crosses the blood brain barrier and affects the cognitive function of the patient •Manifestations: -Drowsiness -Agitation -Slurred speech -Impaired judgment -Confusion -Memory loss -Can progress to coma •Fetor hepaticus When asked to hold the arms and hands stretched out, the patient is unable to hold this position, and there will be a series of rapid flexion and extension movements of the hands. Deterioration of handwriting & inability to draw a simple star figure occurs with progressive HE

Collaborative Care & Drug Therapy Acute Pyelonephritis

•Antibiotics -PO or IV •Adequate fluid intake •NSAIDs or antipyretic drugs •Urinary analgesics •Follow up urine C & S and imaging studies •Recognize manifestations of recurrence or relapse •REST Drug therapy Antibiotics Parenteral administration in hospital to rapidly establish high drug levels. Continue drugs as prescribed. Adequate fluid intake: The patient should drink at least eight glasses of fluid every day, even after the infection has been treated. NSAIDs or antipyretic drugs Fever Discomfort Urinary analgesics Follow-up urine C & S and imaging studies Relapses may be treated with 6-week course of antibiotics Follow-up urine culture and imaging studies Re-infections treated as individual episodes or managed with long-term therapy Prophylaxis may be used for recurrent infection Rest to increase comfort

Assessment & Management Ascites & Edema

•Assessment: of skin breakdown & abdominal appearance & dullness, of respiratory status, of peritonitis, of pain; measurements of extremities & abdominal girth, weight; I/O's, electrolyte imbalance, VS's •Steps to prevent skin breakdown •Steps to minimize respiratory distress

Prostate Cancer Clinical Manifestations

•Asymptomatic early •Late symptoms similar to BPH •Radiating pain with urinary symptoms may indicate metastasis •Early diagnosis and treatment •Metastasis pelvis, bones, bladder, lungs, liver (Pain Management) •See Table 54-5 for Staging S/SX: dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption of urinary stream, inability to urinate Mets: pain in lumbosacral area that radiates down to the hips or legs •Pain in the lumbosacral area that radiates down to the hips or legs, when combined with urinary symptoms, may indicate metastasis. •The tumor can spread to the pelvic lymph nodes, bones, bladder, lungs, and liver. Once the tumor has spread to distant sites, the major problem becomes the management of pain. As the cancer spreads to the bones (a common site of metastasis), pain can become severe, especially in the back and the legs because of compression of the spinal cord and destruction of bone.

Urinary Tract Calculi Collaborative Care 2

•Endourologic procedures for stones •Cystoscopy •Flexible ureteroscope •Cystolitholathopaxy •Cystoscopic lithotripsy •Percutaneous nephrolithotomy •Indications for endourologic stone removal, lithotripsy, or open surgical stone removal include •Stones too large for passage •Association with bacteriuria •Causing impairment in renal function •Causing persistent pain, nausea, or paralytic ileus •If the stone is located in the bladder, a cystoscopy is done to remove small stones. •Flexible ureteroscopes, inserted via a cystoscope, can be used to remove stones from the renal pelvis and upper urinary tract. •For large stones (Fig. 46-6), a cystolitholapaxy is done. In this procedure, large stones can be broken up with an instrument called a lithotrite (stone crusher). •The bladder is then irrigated and the crushed stones washed out. In a cystoscopic lithotripsy, an ultrasonic lithotrite is used to pulverize (break up) stones. •In percutaneous nephrolithotomy, a nephroscope is inserted into the renal pelvis through a track (with the use of a sheath) in the skin in the patient's back. The kidney stones can be fragmented with ultrasonic, electrohydraulic, or laser lithotripsy. The stone fragments are removed, and the pelvis is irrigated. •The primary indications for surgery include pain, infection, and obstruction. •A nephrolithotomy is an incision into the kidney to remove a stone. •A pyelolithotomy is an incision into the renal pelvis for stone removal. •If the stone is located within the ureter, a ureterolithotomy is performed. •A cystotomy may be indicated for bladder calculi. •The most common complications following surgical procedures for stone removal are related to hemorrhage. •See Lewis et. al, pages 1094-1095 for discussion of surgery of the urinary tract...renal and ureteral surgery...concentrating on the Postoperative Management. Will also discuss under Kidney Cancer and nephrectomy.

Urinary Tract Calculi Nutritional Therapy

•Avoid or limit carbonated beverages, coffee & tea •Adequate fluid intake especially water (caution with acute episode with obstruction/colic) •Restrict sodium (high sodium increases calcium excretion in urine) •Restrict purines with uric acid kidney stones •Avoid foods high in oxalate (commonly found in stones) •High calcium dietary intake reduces urinary excretion of oxalate •See Table 45-12 for Nutritional Therapy for foods high in purines, calcium & oxalate •Consumption of colas, coffee, and tea should be limited because high intake of these beverages tends to increase rather than diminish the risk of recurring urinary calculi. •To manage an obstructing stone, have the patient drink adequate fluids to avoid dehydration. •Forcing excessive fluids is not advised because this has not proved effective in facilitating spontaneous "passage" (excretion) of stones via the urine, and it may also increase the pain or precipitate the development of renal colic. •Increasing the fluid intake is particularly important for patients at risk for dehydration, including those who (1) are active in sports, (2) live in a dry climate, (3) perform physical exercise, (4) have a family history of stone formation, and/or (5) work outside or in an occupation that requires a great deal of physical activity. Adequate fluid intake: to produce approximately 2 L of urine per day. Moderately active, ambulatory persons should drink about 3 L/day. •Fluid intake will need to be higher in the active patient who works outdoors or who regularly engages in athletic activities. •Water is the preferred fluid. •A low-sodium diet is recommended because high sodium intake increases calcium excretion in the urine. Previously restricted Calcium dietary intake. Now increase calcium intake lowers risk of stones due to decrease in urinary excretion of oxalate.

VIRAL HEPATITIS DIAGNOSTIC STUDIES

•Blood tests for specific types of viral hepatitis •Liver function tests •Prothrombin time •Serum proteins •Liver biopsy for chronic hepatitis

Cirrhosis

•Chronic progressive disease in which the hepatocytes are destroyed (end-stage) •Extensive degeneration and destruction of the liver cells •Inadequate blood flow and scar tissue lead to an overall decrease in the functioning of the liver •Typically cirrhosis has an insidious onset •8th leading cause of death in the US

Cirrhosis complications

•Compensated cirrhosis •Decompensated cirrhosis -Portal hypertension -Peripheral edema -Abdominal ascites -Esophageal and gastric varices -Hepatic encephalopathy -Hepatorenal syndrome

Prostate Cancer Collaborative Care

•Conservative therapy -"Watchful waiting" or "deferred treatment" •Surgical therapy -Radical prostatectomy (Open vs. Laparascopic) -Nerve-sparing procedure Early recognition and treatment are important. Control tumor growth. Prevent metastasis. Preserve quality of life. 90% are initially diagnosed when the cancer is in a local or regional stage - survival rate is 100% at this stage. Prostate Cancer Survival Rates In most individuals, prostate cancer progresses slowly through stages; about all individuals diagnosed with stage I to III prostate cancer survive 5 years or longer and with current treatments, the outlook is even better for future survival. Even stage IV has a 5-year survival rate of about 31% and this figure may also increase with advancement in treatment methods. Treatments: Conservative: life expectancy <10 years, low-grade, low-stage tumor. Frequent PSA, DRE, symptoms Treatment: Watch and Wait Watchful waiting when Life expectancy is less than 10 years Presence of low-grade, low-stage tumor Serious coexisting medical conditions "Watch and wait," is a phrase that is being used more frequently with some patients with prostate cancer. It means that if your cancer is not aggressive (based on the Gleason score and the cancer stage), treatments may be deferred and your condition periodically checked. This approach is used because the risks of urinary and sexual problems inherent in most prostate cancer treatments are serious and may be put off or avoided if the cancer is not aggressive. However, aggressive prostatic cancer is usually treated even if secondary complications of treatments are serious. http://www.medicinenet.com/prostate_cancer_pictures_slideshow/article.htm Treatment: Prostate Cancer Surgery Radical prostatectomy is the surgical removal of the prostate gland. Usually, this treatment is performed when the cancer is located only in the prostate gland. New surgical techniques help avoid damage to nerves, but the surgery may still have the side effects of erectile dysfunction and impaired urinary functions. However, these side effects may gradually improve in some patients. Radical Prostatectomy: Entire prostate, seminal vessicles, part of the bladder (neck) are removed. Retroperitoneal lymph node dissection. Surgery not considered for stage "D" cancer due to metastatic disease. Nerve Sparing procedure: neurovascular bundles maintain erectile function. Not indicated for patients with cancer outside the prostate gland. Risk of erectile dysfxn reduced, no guarantee of potency. Other:

Balloon Tamponade: Sengstaken-Blakemore Tube

•Controls the hemorrhage by mechanical compression of the varices. •Nursing care includes monitoring for complications of rupture or erosion of the esophagus, regurgitation and aspiration of gastric contents, and occlusion of the airway by the balloon. Safety alert: •Label lumens •Measures to ↓necrosis •Protect airway --This procedure is used less, as it is not ideal

Assessment/Care of Acute Kidney Injury - DIURETIC PHASE

•Daily urine output is 1 to 3 L or much more •Monitor for hyponatremia, hypokalemia, and dehydration

Prostate Cancer: Nursing Diagnoses

•Decisional conflict •Acute pain •Urinary retention •Impaired urinary elimination •Sexual dysfunction •Anxiety

Hepatitis

•Definition: -Inflammation of the liver •Causes: -Viruses, drugs (alcohol), chemicals, autoimmune diseases, and metabolic abnormalities

Cirrhosis Clinical Manifestations: Peripheral Neuropathy

•Dietary deficiencies of thiamine, folic acid, and cobalamin (vitamin B12) (common with ETOH cirrhosis) •Sensory and motor symptoms -Sensory symptoms may predominate •Revisit slide 12

Intra-Renal Causes of AKI

•Direct damage to the kidneys → impaired renal function •ATN: 90% of all intrarenal AKI •Inability to concentrate urine with fixed SG = 1.010 & urine osmol = 300 mmol/kg; casts, proteinuria •Prevention/Treatment

Cirrhosis Clinical Manifestations continued

•Early (may be asymptomatic or compensated) -Fatigue -GI symptoms -Abdominal pain (RUQ) -Palpable liver -Others •Late -See Figure -Often result from liver failure & portal HTN -In advanced stages liver is small & nodular (Diminished function)

VIRAL HEPATITIS PREVENTION - A & B

•Hepatitis A -Personal hygiene -Water supply -Restaurants -Animal care -Active immunization •Recommended areas of high rate of hepatitis A (Hep A vaccine) -Passive immunization •Immune globulin •Prophylactic before and after exposure •Hepatitis B -Control of blood, blood products & skin-piercing instruments -Personal hygiene -Active immunization •Recommended for all people (Hep B vaccine) -Passive immunization •Immune globulin •Hepatitis B immune globulin (HBIG) - Exposure to hep B

Benign Prostatic Hyperplasia (BPH)

•Enlargement of prostate gland •Possible endocrine changes with aging •Enlargement compresses urethra -Partial or complete obstruction -Clinical symptoms •Multiple Risk factors -Aging is main one Enlargement of prostate gland resulting from increase in number of epithelial cells and stromal tissue. Most common urologic problem in male adults. About 50% of all men will develop BPH in their lifetime. •Possible endocrine changes •DHT is dihydroxytestosterone, the principal intraprostatic androgen in the cells of the prostate. •In older men there is a decrease in the blood's testosterone level, but they continue to produce and accumulate high levels of DHT in the prostate. •Throughout their lives, men produce both testosterone and small amounts of estrogen. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. A higher amount of estrogen within the gland increases the activity of substances (e.g., DHT) that promote cell growth. •Typically BPH develops in the inner part of the prostate. •Prostate cancer is most likely to develop in the outer part. •This enlargement gradually compresses the urethra, eventually leading to partial or complete obstruction. It is the compression of the urethra that ultimately leads to the development of clinical symptoms. Risk factors for BPH Aging Obesity Especially increased waist circumference Lack of physical activity Alcohol consumption Erectile dysfunction Smoking Diabetes

Focus on : Radical Prostatectomy

•Entire gland, seminal vesicles, and part of bladder neck are removed. •Retroperineal lymph node dissection usually is done. •Considered most effective for long-term survival •Nerve-sparing procedure •Radical Prostatectomy •The entire prostate is removed because cancer tends to be in many different locations within the gland. •A retroperitoneal lymph node dissection is usually done as a separate procedure. •Surgery is usually not considered an option for advanced stage disease because metastasis has already occurred. •A. Retropubic approach involves a midline abdominal incision. The pelvic lymph nodes can be dissected. •B, Perineal approach involves an incision between the scrotum and anus. Perineal resection: incision is made between scrotum and anus. Can't remove lymph nodes. Higher risk of post-operative infection due to proximity to anus and possible contamination with stool. Careful dsg changes after bowel movements. •A laparoscopic approach to prostatectomy is being used in some settings. In this method four small incisions are made into the abdomen. This results in less bleeding, less pain, and a faster recovery compared with other approaches. Erectile Dysfunction: decreased risk with nerve sparing surgery. Nerve-sparing surgical procedure: Spares nerves responsible for erection, Only for cancer confined to prostate, No guarantee that potency will be maintained, Most young men (<50 years of age) with good preoperative erectile function and low-stage prostate cancer can expect a return of potency after nerve-sparing prostatectomy.

Assessment/Care of Acute Kidney Injury - OLIGURIA PHASE

•Fluid Volume Overload •May be life threatening •Urinalysis findings •May also have non-oliguric cases •See AKI/CKD Chart Metabolic acidosis •Kussmaul respirations (ABG results?)-blow off CO2 Sodium balance •Hyponatremia can lead to cerebral edema Potassium excess •ECG changes •May be life-threatening •Hematologic disorders •Leukocytosis; ↑Risk for Infection •Azotemia •Neurologic disorders •Fatigue and difficulty concentrating •Seizures, stupor, coma •Other abnormal labs: UA, Mg+, HCT, PLT, CA+, PO-

Functions of Liver: Bile Synthesis & Excretion & Conjugation and Secretion of Bilirubin

•Formation of bile, containing bile salts, bile pigments (mainly bilirubin) & cholesterol -Emulsification of fats and aid in absorption of fatty acids and fat-soluble vitamins (A, D, E, K) •Unconjugated bilirubin (insoluble) is conjugated (water soluble) with glucuronic acid and excreted in intestines...

Gallbladder disease risk factors

•Gallbladder disease is a common health problem in the United States. •It has been estimated that up to 10% of American adults have cholecystitis caused by gallstones. The actual number is not known because many persons with stones are asymptomatic. •Health Promotion: Be aware of predisposing factors of gallbladder disease in general health screening. Members of ethnic groups in which the disease is more common, such as Native Americans, should be taught initial manifestations and instructed to see their health care provider if these manifestations occur. •Cholelithiasis is more common in women, especially multiparous women, and women over 40 years of age. •Postmenopausal women on estrogen replacement therapy and younger women on oral contraceptives are at an increased risk of gallbladder disease. Oral contraceptives affect cholesterol production and increase the likelihood of gallbladder cholesterol saturation. •Other factors that increase the occurrence of gallbladder disease are a sedentary lifestyle, a familial tendency, and obesity. Obesity causes increased secretion of cholesterol in bile. •The incidence of gallbladder disease is especially high in the Native American population, particularly in the Navajo and Pima tribes. •Men Incidence of cholelithiasis is lower in men than in women. • Gender differences in incidence decrease after age 50.Women: Pregnancy is the greatest risk factor for increased prevalence in women. Obesity increases the risk, especially for women.

Benign Prostatic Hyperplasia (BPH)Clinical Manifestations

•Gradual onset from obstruction •Obstructive symptoms •Decrease force of stream with dribbling •Difficulty initiating voiding (Stop/Start) •Incomplete bladder emptying •Irritative symptoms •Frequency, urgency, dysuria, pain, nocturia, incontinence •Associated with inflammation or infection •American Urological Association Symptom Index •Tool to assess voiding symptoms: Table 54-1. •The patient's symptoms are usually gradual in onset and may not be noticed until prostatic enlargement has been present for some time. Symptoms are usually gradual in onset. Manifestations associated with obstruction of lower urinary tract Early symptoms are usually minimal because bladder can compensate. Worsen as obstruction increases •Obstructive symptoms •Symptoms due to urinary retention •Decrease in caliber and force of urinary stream •Difficulty in initiating urination •Intermittency •Starting and stopping stream several times while voiding •Dribbling at end of urinating §Irritative symptoms §Symptoms associated with inflammation or infection §Urinary frequency and urgency §Dysuria §Bladder pain §Nocturia §Incontinence •The American Urological Association (AUA) symptom index for BPH (see Table 55-1) is a widely used tool to assess voiding symptoms associated with obstruction. •Although this tool is not diagnostic, it is useful to determine the extent of symptoms. •Higher scores on this tool indicate greater symptom severity.

Benign Prostatic Hyperplasia (BPH)Diagnostic Studies

•History and physical •Digital Rectal Examination (DRE) •UA with culture •Prostate-specific antigen (PSA) •Serum creatinine •Neuro exam •Transrectal ultrasound (TRUS) •Uroflometry •Cystoscopy •Using DRE, the health care provider can estimate the size, symmetry, and consistency of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth. •A urinalysis with culture is routinely done to determine the presence of infection. The presence of bacteria, white blood cells, or microscopic hematuria is an indication of infection or inflammation. •A prostate-specific antigen (PSA) blood test may be done to rule out prostate cancer. However, PSA levels may be slightly elevated in patients with BPH. Serum creatinine levels may be ordered to rule out renal insufficiency. Because symptoms of BPH are similar to those of a neurogenic bladder, a neurological examination may also be performed. •TRUS scan allows for accurate assessment of prostate size and is helpful in differentiating BPH from prostate cancer. Biopsies can be taken during the ultrasound procedure. •Uroflowmetry is helpful in determining the extent of urethral blockage and thus the type of treatment needed. •Cystoscopy is performed if the diagnosis is uncertain and in patients who are scheduled for prostatectomy. Digital Rectal Examination PSA-rules prostate cancer-PSH can be slightly elevated in BPH Creatinine-R/O renal insufficiency Uroflometry: measures volume of urine expelled from the bladder per second Cystoscopy: allows for internal visualization of the urethra and bladder PVR: degree of obstruction How Will Your Doctor Diagnose BPH? Diagnosis of BPH is based upon taking a history of your symptoms. Tests that may be carried out include: A rectal examination to assess the size and shape of the prostate Ultrasound examination Biopsy of the prostate Urine flow studies Cystoscopy, in which the doctor can see and evaluate the inside of the bladder http://www.medicinenet.com/enlarged_prostate_bph_pictures_slideshow/article.htm

Liver disease Nursing Diagnoses (see eNCP)

•Imbalanced nutrition •Impaired skin integrity •Excess fluid volume •Dysfunctional family processes •Collaborative Problems: -Hemorrhage -Hepatic encephalopathy

Hepatitis Nursing Diagnoses

•Imbalanced nutrition: less than body requirements related to anorexia, nausea, and reduced metabolism of nutrients by liver •Activity intolerance related to fatigue and weakness •Risk for impaired liver function related to viral infection

Acute Glomerulonephritis Pathophysiology

•Immunologic inflammatory process affecting the renal glomeruli •Type I: Auto-Abs specific for Ags within the glomerular basement membrane lead to inflammation •Type II: Abs react with circulating nonglomerular Ags and cause inflammation •See Table 45-8 for causes/risk factors Overview of GlomerulonephritisGlomerulonephritis is an immunologic inflammatory process affecting the renal glomeruli, resulting from two different types of antibody-induced injury. •In the first type, an unknown mechanism stimulates the development of autoantibodies specific for antigens within the glomerular basement membrane. •In the second type of immune process, antibodies react with circulating nonglomerular antigens, such as bacterial products or viral agents, and are randomly deposited as immune complexes along the glomerular basement membrane. • All forms of immune complex diseases are characterized by an accumulation of antigen, antibody, and complement in the glomeruli, which can result in inflammation and tissue injury. In most cases, recovery from the acute illness is complete. Tubular, intersitial, and vascular changes also occur. If progressive involvement occurs, the result is destruction of renal tissue and marked renal insufficiency. Affects both kidneys and is 3rd leading cause of ESKD in the US

UTI Nursing Diagnoses and Goals

•Impaired urinary elimination •Readiness for enhanced self-health management •See eCarePlan •Other interventions with acute UTI: •Continue to increase fluid intake •Application of local heat to suprapubic or lower back may relieve discomfort Patient will have •Relief from lower urinary tract symptoms •Prevention of upper urinary tract involvement •Prevention of recurrence

Etiology & Pathogenesis of Acute Pancreatitis

•In the United States, the most common cause is gallbladder disease (gallstones) or obstructed stone and often treated with ERCP (discussed with GB disorders), followed by chronic alcohol intake. •Smoking is an independent risk factor for acute pancreatitis. •Biliary sludge or microlithiasis, which is a mixture of cholesterol crystals and calcium salts, is found in 20% to 40% of patients with acute pancreatitis. The formation of biliary sludge is seen in patients with bile stasis. •Acute pancreatitis attacks are also associated with hypertriglyceridemia (serum levels >1000 mg/dL). • Other less common causes include certain drugs (corticosteroids, thiazide diuretics, oral contraceptives, sulfonamides, NSAIDs), metabolic disorders (hyperparathyroidism, renal failure), and vascular diseases. •Pancreatitis may occur after surgical procedures on the pancreas, stomach, duodenum, or biliary tract. Pancreatitis can also occur after endoscopic retrograde cholangiopancreatography (ERCP). •In some cases, the cause is unknown (idiopathic). •Other less common causes of acute pancreatitis include trauma (postsurgical, abdominal), viral infections (mumps, coxsackievirus B, HIV), penetrating duodenal ulcer, cysts, abscesses, cystic fibrosis, and Kaposi sarcoma. •The most common pathogenic mechanism is autodigestion of the pancreas. •The etiologic factors cause injury to pancreatic cells or activation of the pancreatic enzymes in the pancreas rather than in the intestine. •This may be due to reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. This reflux may be due to blockage created by gallstones. Obstruction of pancreatic ducts results in pancreatic ischemia. •Trypsinogen is an inactive proteolytic enzyme produced by the pancreas. It is released into the small intestine via the pancreatic duct. In the small intestine, it is activated to trypsin by enterokinase. Normally, trypsin inhibitors in the pancreas and plasma bind and inactivate any trypsin that is inadvertently produced. In pancreatitis, activated trypsin is present in the pancreas. This enzyme can digest the pancreas and produce bleeding.

Kidney Cancer

•Incidence: 65,000 new cases per year, 2x more in male vs. female; 50-70 years old •Renal cell carcinoma (adenocarcinoma) most common •Cigarette smoking most significant risk factor Kidney cancer: about 65,000 newly diagnosed cases per year in US. Twice as often in men vs. women, ages 50-7- years Most common type of cancer is the adenocarcinoma Cigarette smoking most significant risk factor. Other risk factors: familila, obesity, HTN, exposure to harmful chemicals such as abestos and cystic disease associated with ESKD

Acute Pancreatitis Clinical Manifestations-Cullen's Sign vs Grey Turner's sign

•Intravascular damage from circulating trypsin may cause areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration). These result from seepage of blood-stained exudate from the pancreas and may occur in severe cases. •

Urinary Diversion Nursing Management - Continent

•Kock Pouch •The pouch is emptied using a catheter. The tip of the catheter is inserted gently into the tip of the pouch, allowing the contents of the pouch to flow directly into the toilet. Most patients cover the stoma site with an adhesive dressing to absorb the mucus that accumulates at the opening. This mucus formation is natural, and makes insertion of the catheter easier. Intra-abdominal urinary reservoir. Constructed from the ileum, ileocecal segment or colon. Continence mechanism is formed by intussusception of a portion of the bowel. Then the patient does not leak. Pouches: self-cath every 4-6 hours, does NOT need to wear external pouches Small bandage on surface to collect mucus or excess drainage

Upper UTI Symptoms Acute Pyelonephritis

•LUTS's (cystitis symptoms) •Upper: Flank pain/costovertebral tenderness or pain •Systemic: •Chills, N, V •Fever & ↑WBC •Mild fatigue to malaise •Can lead to...urosepsis Pyelonephritis: inflammation of the renal parenchyma-systemic symptoms. •Manifestations usually subside in a few days, even without therapy. Bacteriuria and pyuria still persist. •The patient with mild symptoms may be treated as an outpatient with antibiotics for 14 to 21 days. •Hospitalization for patients with severe infections and complications Such as nausea and vomiting with dehydration. If bacteremia is a possibility, close observation and vital sign monitoring are essential. Prompt recognition and treatment of septic shock may prevent irreversible damage or death. • When initial treatment alleviates acute symptoms and the patient is able to tolerate oral fluids and drugs, the patient may be discharged on a regimen of oral antibiotics for an additional 14 to 21 days.

Bladder Cancer Surgical Incisions

•Laparoscopic cystectomy with ileal conduit •Traditional incision with ileal conduit Laparoscopic cystectomy with ileal conduit vs. traditional incision Top figure: Fig. 2 Laparoscopic cystectomy and ileal conduit formation .... http://www.uroweb.org/gls/EAUN/epub/EAUN_2009_LR.html Benefits of a laparoscopic approach include reduced blood loss, less blood transfusion requirements. [55] Pruthi et al. (2003) [116] looked at improving care pathways through the pre-, peri- and postoperative stages of patients undergoing radical cystectomy to allow for early institution of an oral diet and early hospital discharge, and thereby overall improvements in patient recovery and outcomes after this procedure. Improvements such as limiting pre-operative bowel preparation, changes in surgical technique (i.e. reduced incision length), use of internal surgical stapling devices and, post-operatively, early nasogastric tube removal, use of nonnarcotic analgesics and early resumption of diet.

TURP: Home and Ambulatory Care

•May be discharged with Foley •Potential complications •Urinary leakage SP DC Foley •Urinary retention & urinary incontinence •Persistent clots •Foley Removal •Poor sphincter tone...incontinence....Kegel exercises •Hydration 2-3L daily •S/Sx infection to monitor for •Prevent constipation •Avoid heavy lifting •Driving limitations •Sexual Function: Retrograde Ejaculation •Avoid bladder irritants •Yearly DREs •The bladder may take up to 2 months to return to its normal capacity. •Instruct the patient to drink at least 2 L of fluid per day and to urinate every 2 to 3 hours to flush the urinary tract. •Foley often removed 2-4 days after surgery. Risk for poor sphincter tone=urinary incontinence=Kegel exercises 10-20 times per hour while awake. Practice starting and stopping stream. Urinary incontinence can be permanent=incontinence clinic. Other methods: penile clamp, condom catheter, incontinence pads for dribbling. Insertion of occlusive cuff that serves as an artificial sphincter can be surgically implanted. •Preventing constipation •Avoiding heavy lifting: Not more than 10 lb or 4.5 kg •Refraining from driving, intercourse after surgery as directed •Erectile dysfunction: Inform the patient that surgery may affect sexual functioning. The ejaculate may be decreased in amount or totally absent. Sexual counseling if erectile dysfunction becomes a problem. •Retrograde ejaculation: semen discharged into bladder. May produce cloudy urine. Many men experience retrograde ejaculation because of trauma to the internal urethral sphincter. This may decrease orgasmic sensations felt during ejaculation. Retrograde ejaculation is not harmful because the semen is eliminated during the next urination. •Point out that although some patients experience concerns regarding change in sexual function, this is not a universal concern. Recovery depends on the type of surgery performed and the interval of time between when symptoms first appeared and the date of surgery. It may take up to 1 year for complete sexual function to return. •Bladder irritants include caffeine products, citrus juices, and alcohol.

Multisystem Effects of CKD

•May see some of these effects in AKI as well •See AKI/CKD Chart •See Table 46-10 for nutritional therapy 7 Table 46-11 for high-potassium foods

UTI Risk Factors

•Microorganisms •Introduced via ascending route via urethra •Gram-negative bacteria (GI system) •Urologic instrumentation •Intercourse ("Honeymooner's cystitis") •HAI's (E. coli) •CAUTI's •Multiple other Risk Factors (See Table 45-2) Ascending route: Organisms introduced via the ascending route from urethra and originate in the perineum. Gram-negative bacilli normally found in GI tract: common cause Urologic instrumentation allows bacteria to enter urethra and bladder. Allows bacteria present in opening of urethra to enter urethra or bladder. Sexual intercourse promotes "milking" of bacteria from perineum and vagina. May cause minor urethral trauma Hospital-acquired UTI accounts for 31% of all nosocomial infections Causes Often: E. coli Seldom: Pseudomonas species Catheter-acquired UTIs Bacteria biofilms develop on inner surface of catheter •Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder Foreign bodies Examples: catheters, calculi, instrumentation Anatomic factors Examples: obesity, congenital defects, fistula Compromising immune response factors Examples: age, HIV, diabetes (People who have diabetes are at higher risk for UTIs because the high sugar (glucose) levels in the blood can result in high sugar levels in the urine and result in a good growth environment for bacteria. People who have diabetes often have an immune system that does not respond as well to infections. Diabetes can damage nerves that result in incomplete bladder emptying thus encouraging bacterial survival and retrograde infections. http://www.medicinenet.com/urinary_tract_infection_uti_pictures_slideshow/article.htm Predisposing factors Functional disorders Example: constipation Other factors Examples: pregnancy, multiple sex partners (women) Risk factors for UTIs were presented previously, but besides being a woman who is sexually active or someone who is elderly or immunocompromised, there are other risk factors: Not drinking enough fluids (slows the wash of pathogens out of the body) Taking frequent baths (soaking in fluid that may promote retrograde infections) Waiting to urinate (promotes retrograde bacterial movement) Kidney stones (causes slowing or partial blockage of urine flow) Urinary Tract Infections in Men Adult men have infrequent UTIs; if they get a UTI there usually is an underlying cause (for example, having an enlarged prostate or kidney stone or being an elderly person with a catheter).

Etiology of Cirrhosis

•Most common causes in United States are chronic hepatitis B (25%) & C (20%) and alcohol-induced liver disease •Other causes -Extreme dieting, malabsorption, obesity -Environmental factors -Genetic predisposition -Drug Induced (APAP, amoxicillin-clavulanate) -Biliary cirrhosis •Primary biliary cirrhosis (PBC) or cholangitis (autoimmune) •Primary sclerosing cholangitis (PSC) (inflammation) -Cardiac cirrhosis •Results from long-standing severe right-sided heart failure -NAFLD

Upper UTI: Acute Pyelonephritis Etiology and Pathophysiology

•Most commonly caused by bacteria •Begins lower urinary tract & ascends •Vesicoureteral reflux •Dysfunction of lower urinary tract •Recurrence can lead to chronic pyelonephritis →CKD Usually begins with colonization and infection of lower tract via ascending urethral route Frequent causes Escherichia coli Proteus Klebsiella Enterobacter Preexisting factor usually present Vesicoureteral reflux Backward movement of urine from lower to upper urinary tract Dysfunction of lower urinary tract Obstruction from BPH Stricture Urinary stone •For residents of long-term care facilities, urinary tract catheterization is a common cause of pyelonephritis and urosepsis.

Acute Pancreatitis Other Clinical Manifestations

•N & V •Low-grade fever •Tachycardia / decreased B/P •Generalized jaundice (with obstruction) •Abdominal tenderness, rigidity/guarding •Decreased bowel sounds/paralytic ileus •Abdominal distention •Crackles •Other s & S include N & V, low grade fever •Abdominal tenderness with muscle guarding is common; ileus •Bowel sounds may be decreased or absent. Paralytic ileus may occur and causes marked abdominal distention. •The lungs are frequently involved, with crackles present. •Shock may result from hemorrhage into the pancreas, toxemia from the activated pancreatic enzymes, or hypovolemia as a result of fluid shift into the retroperitoneal space (massive fluid shifts).

Urinary Tract Calculi Diagnostic Studies

•Noncontrast spiral CT (CT/KUB) + others •Complete urinalysis to assess for •Hematuria •Crystalluria •pH •Retrieval and analysis of stones •Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, creatinine measurements Besides careful history and clinical maniestations will do: Noncontrast spiral CT, also called CT/KUB, is usually the diagnostic study used in patients with renal colic. It is quick and noninvasive and requires no IV contrast material. May do US or IVP as well. •Measurement of urine pH is useful in the diagnosis of struvite stones and renal tubular acidosis (tendency for alkaline or high pH) and uric acid stones (tendency for acidic or low pH). •Patients who form stones recurrently should undergo a 24-hour urinary measurement of calcium, phosphorus, magnesium, sodium, oxalate, citrate, sulfate, potassium, uric acid, and total volume. Retrieval and analysis of the stones are important in the diagnosis of the underlying problem contributing to stone formation. Patient sent home with strainer. To ensure that any spontaneously passed stones are retrieved, strain all urine voided by the patient, using gauze or a urine strainer. CT: differentiate stone from tumor IVP: identify degree and site of obstruction, (contraindicated with renal failure) Labs: serum calcium, phos, sodium, potassium, bicarbonate, uric acid, BUN, creatinine 24 hour urine for recurrent stone formers

Effects of Drugs on Decreasing Portal Blood Flow and Pressure

•Oral Non-Selective Beta Blockers -Decrease CO by blocking B1 receptor in heart -Splanchnic (splaNGknik) vasoconstriction by blocking vasodilator effects of B2 stimulation •IV Octreotide (somatostatin analog) -Splanchnic vasoconstriction •IV Vasopressin -Potent splanchnic vasoconstriction

Prostate Cancer Diagnostic Studies

•PSA (prostate-specific antigen) blood test •Digital rectal exam (DRE) •Prostatic acid phosphatase (PAP) •Biopsy: Definitive •Imaging PSA (prostate-specific antigen) blood test. PSA-glycoprotein produced by prostate: elevations might be BPH, recent ejaculations, acute or chronic prostatitis or after long bike rides, also cystoscopy, indwelling catheters, and prostate biopsies can cause elevation. Proscar and Avodart cause decrease in PSA. PSA levels also used to monitor success of treatment. Elevated levels indicate prostatic pathology—not necessarily cancer. Marker of tumor volume when cancer exists. Also used to monitor success of treatment •Mild elevations in PSA may occur with aging, BPH, recent ejaculation, acute or chronic prostatitis, or after long bike rides. •In addition, cystoscopy, indwelling urethral catheters, and prostate biopsies may also produce elevated PSA levels. •Decreases in the PSA level can occur with drugs such as finasteride (Proscar) and dutasteride (Avodart). Digital rectal exam (DRE): Abnormal prostate findings include hardness, nodular and asymmetric. Annual DRE and PSA starting age 50 With advanced prostate cancer, serum alkaline phosphatase is increased as a result of bone metastasis. Neither a PSA nor DRE is a definitive diagnostic test. Biopsy of prostate tissue is necessary to confirm diagnosis.Done using TRUS to allow physician to visualize and pinpoint abnormalities Imaging: Bone scan, CT, MRI with endorectal probe, and TRUS are used to determine location and spread. DRE and PSA Screening A digital rectal exam (DRE) is done to determine if the prostate is enlarged and is either soft or has bumps or is very firm (hard prostate). Another test done on a blood sample can determine the level of a protein (prostate-specific antigen or PSA) produced by prostate cells. The PSA test may indicate a person has a higher chance of having prostate cancer but controversies about the test exist (see following slide). The patient and his doctor need to carefully consider the meaning and the use of these test results. http://www.medicinenet.com/prostate_cancer_pictures_slideshow/article.htm PSA Test Results As stated above, the PSA test has some problems associated with it. In general, a PSA level less than 4 nanograms per mililiter (ng/mL) of blood is considered a normal level while a PSA greater than 10 ng/mL suggests a high risk of having cancer. Unfortunately, some men have intermediate levels (5 to 9 ng/mL) and some men can have prostate cancer with PSA levels less than 4 ng/mL. In addition, BPH and prostatitis can increase PSA levels resulting in a false positive test while some drugs may lower PSA levels and result in a false negative PSA test. Your doctor can help decide the meaning of both the PSA test and the digital rectal exam results and determine if additional tests need to be done. http://www.medicinenet.com/prostate_cancer_pictures_slideshow/article.htm Prostate Cancer Biopsy If your doctor determines that the PSA and digital rectal exam suggest prostate cancer, the physician may suggest that a biopsy of the prostate is warranted, depending on your age, medical condition, and other factors. A biopsy is done by inserting a needle through the rectum or between the rectum and scrotal junction and then removing small samples of prostatic tissue that can be examined under a microscope for cancer tissue. The biopsy may detect and determine the aggressiveness of prostatic cancer cells. Biopsy and Gleason Score Biopsy samples from the prostate gland are examined by a pathologist. The pathologist then gives the tissue a grade of 1to 5 with 5 as the worst grade of tumor pattern. Then the pathologist looks at the individual cells in the tumor pattern and grades the cell types from 1 to 5 with 5 being the most aggressive cancer cell type. The Gleason score is based on the sum of these two numbers. A Gleason score of 5 + 5 = 10 indicates a highly aggressive prostate tumor while a low score (2 + 2 = 4) indicates a less aggressive cancer. http://www.medicinenet.com/prostate_cancer_pictures_slideshow/article.htm Prostate Cancer Imaging Prostatic cancer spread may be detected by several different tests such as ultrasound, CT, MRI, and a radionuclide bone scan. Doctors will help determine which tests are best for each individual patient. Prostate Cancer Staging Prostate cancer staging is a method that indicates how far the cancer has spread in the body and is used to help determine the best treatment method for the patient. Cancer that has spread to other body sites or organs is termed metastatic cancer. In terms of prostate cancer, the cancer stages are as follows: Stage I: The cancer is small and still contained within the prostate gland. Stage II: The cancer is more advanced, but is still confined within the prostate gland. Stage III: The cancer has spread to the outer part of the prostate and to the nearby seminal vesicles. Stage IV: The cancer has spread to lymph nodes, other nearby organs, or tissues such as the rectum or bladder, or to distant sites such as the lungs or bones. Aggressive prostate cancer often reaches stage IV but others that are less aggressive may never progress past stage I, II, or III.

Bladder Cancer Focus on Cystectomy

•Partial cystectomy (segmental) -Removal of portion of bladder wall & tumor •Radical cystectomy -Men: removal of bladder, prostate, seminal vesicles -Women: removal of bladder, uterus, cervix, urethra, and ovaries with urinary diversion •SPO Care Safety Alert: Never clamp or irrigate the Foley or any other drains unless have a specific order and nursing practice protocols/policies to do so. Post-operative care: Refer to notes on renal and ureteral surgery under nephrectomy for other SPO care. Drink large amounts of fluids for the first week after the procedure...initially will be on IV fluids. Self-monitor color and consistency of urine Urine is pink for the first several days after the surgery; should not be bright red or contain blood clots Partial cystectomy: After about 7-10 days after tumor resection with segmental, may see dark red or rust-colored flecks from the healing tumor resection site. DO NOT irrigate catheter or clamp or irrigate any drains unless have specific orders and practice protocols/policies to do so. Partial cystectomy surgery FAQ's with good images: http://www.laparoboticsurgery.com/minimally-invasive-surgery/bladder-ureteral-cancer/partial-cystectomy-faqs/ Treatment: Surgery Early stage cancers are most commonly treated by transurethral (through the urethra or tube from which urine exits the body) surgery. If cancers have spread, a portion of the bladder (partial cystectomy) or the entire bladder (radical cystectomy) may be performed. Other organs may also be removed such as the uterus and ovaries in women and the prostate in men, if the cancers have spread. Sex After Bladder Cancer Treatment The surgery for bladder cancer can damage nerves in the pelvis, making sex difficult. Some men may have trouble getting an erection, but in younger men, this may improve over time. Semen cannot be produced if the surgery involved removal of the prostate gland and seminal vesicles. Women who undergo surgery for bladder cancer may also find that sex is less comfortable, and achieving orgasm may be difficult. Treatment: After Surgery When the entire bladder is removed, the surgeon will create an alternate way for urine to be stored and passed. This may involve using a portion of the intestine to flow into a urostomy bag. Creation of an artificial bladder is a newer surgical option.

Kidney Cancer: Focus on Surgery

•Partial nephrectomy •Radical nephrectomy •Removal kidney, adrenal gland, surrounding fascia, part of the ureter and lymph nodes Treatment options depends on the stage of the kidney carcinoma: Stage 1-kidney Stage 2-spread to fat but contained w/in the facia Stage 3- Invades renal vein or vena cava or regional lymph node involvement Stage 4- Mets Stage 1-3 radical nephrectomy. Stage 4 radiation therapy is used palliatively in inoperable cases or mets to bone or lungs Partial nephrectomy This operation is commonly used for small kidney cancers that have not spread. The surgeon removes the cancer and part of the kidney surrounding it. Some of the kidney is left behind. Doctors call this nephron sparing surgery. The nephron is the filtering unit of the kidney, so you have some working kidney left after the operation. This type of surgery used to be rare. But many kidney cancers are being found at an early stage, by accident, when you have a scan for something else. This type of treatment is often appropriate for them. If at all possible, removing part of the kidney is used for anyone with a stage 1 kidney cancer (less than 7cm across). In some people, it may not be possible to have this type of surgery, even with a small tumour, because of its position within the kidney Radical nephrectomy The surgeon removes the whole kidney with the tissues around it, including the adrenal gland. The adrenal gland is attached to the kidney. The surgeon also removes some lymph nodes in the area. After nephrectomy for unilateral renal disease, the opposite normal kidney undergoes compensatory hypertrophy, and the glomerular filtration rate is ultimately maintained at 75% of the normal value. Normal life expectancy can be achieved after a unilateral nephrectomy with a normal contralateral kidney.

Benign Prostatic Hyperplasia (BPH)Pre-op /Emergent Care

•Restore urinary drainage •Assess for infection & give antibiotics •Monitor fluid & electrolyte status Pre-op care: Restore urinary drainage prior to surgery. Coude Catheter-use lidocaine gel prior to insertion. Antibiotics. Education re: sexual dysfunction In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter. •Inform the patient that surgery may affect sexual functioning. •The ejaculate may be decreased in amount or totally absent. •Most types of prostatic surgery result in some degree of retrograde ejaculation. •This may decrease orgasmic sensations felt during ejaculation. •Retrograde ejaculation is not harmful because the semen is eliminated during the next urination.

Radical Prostatectomy details

•Patient catheterized for a couple of days •Stay in hospital for 1 to 3 days •Major complications are erectile dysfunction and incontinence. Other complications include hemorrhage, urinary retention, infection, wound dehiscence, DVT, and pulmonary emboli. •Because the perineal approach has a higher risk of postoperative infection (because of the location of the incision relative to the anus), careful dressing changes and perineal care after each bowel movement are important for comfort and to prevent infection. •The incidence of erectile dysfunction is dependent on the patient's age and preoperative sexual functioning, whether nerve-sparing surgery was performed, and the expertise of the surgeon. Sexual functioning following surgery tends to return gradually over at least 24 months or more. Medications such as sildenafil (Viagra) may help improve sexual functioning. •Problems with urinary control may occur for the first few months following surgery because the bladder must be reattached to the urethra after the prostate is removed. Over time, the bladder adjusts, and most men regain control. Kegel exercises strengthen the urinary sphincter and may help improve continence. Coping With Erectile Dysfunction (ED) Erectile dysfunction (ED or failure obtain or sustain an erection) is a very common side effect of most prostate cancer treatments. In some men, especially those under age 70, improved erectile function may occur within about 2 years after surgery. Additionally, the patient may benefit from various ED medications and therapies, including several types of devices specific for men with ED. Men with ED should discuss the various options with their doctor and partner to determine the best individual treatment method(s). Incontinence: bladder must be re-attached to urethra; Kegel exercises,

Prostate Cancer: Brachytherapy

•Placing radioactive seed implants into the prostate gland, allowing higher radiation doses directly in the tissue while sparing the surrounding tissue (rectum and bladder). Brachytherapy involves placing radioactive seed implants into the prostate gland, allowing higher radiation doses directly in the tissue while sparing the surrounding tissue (rectum and bladder). The radioactive seeds are placed in the prostate gland with a needle through a grid template guided by TRUS (Fig. 54-7) to ensure accurate placement of the seeds. Because brachytherapy is a one-time outpatient procedure, many patients find this more convenient than external beam radiation treatment. Brachytherapy is best suited for patients with early stage disease. The most common side effect is the development of urinary irritative or obstructive problems. Some men may also experience ED. The AUA Symptom Index (Table 54-1) can be used to measure urinary function for patients undergoing brachytherapy and can be incorporated into postoperative nursing management. For those with more advanced tumors, brachytherapy may be offered in combination with external beam radiation treatment.24 (Brachytherapy is further discussed in Chapter 15.)

Portal Hypertension

•Portal Blood Supply to Liver -25% from HA -75% from PV -PV brings blood from? Portal HTN results from -Obstruction to normal blood thru portal system secondary to structural changes in the liver with compression/destruction of veins/sinusoids. -Pressure through the portal vein is increased -Complications •Edema/Ascites •Varices •HE •Hepatorenal syndrome

Chronic Pancreatitis Collaborative/Nursing Care

•Prevention of attacks •Relief of pain •Control pancreatic exocrine & endocrine insufficiency •Small bland low-fat, high-carbohydrate diet •Fat-soluble vitamins (bile salts use to help absorption) •Pancreatic enzyme replacement (Pancrelipase) •Control DM •Avoid ETOH and caffeinated beverages •Acid-neutralizing and acid-inhibiting drugs •Surgery •When the patient with chronic pancreatitis is experiencing an acute attack, therapy is identical to that for acute pancreatitis. Will need morphine if on opioids or if not opioid naïve may use fentanyl (duragesic) patch. It sometimes takes large, frequent doses of analgesics to relieve the pain. •The patient does not tolerate fatty, rich, and stimulating foods, and these should be avoided to decrease pancreatic secretions. •Pancreatic enzymes such as pancrelipase (Viokase) and pancrelipase (Cotazym) contain amylase, lipase, and trypsin and are used to replace deficient pancreatic enzymes. They usually are enteric coated to prevent their breakdown or inactivation by gastric hydrochloric acid (HCl) and given with each meal and any in-between meals. Observe stools for stearrhorea and monitor weight to help determine the effectiveness of the enzymes and to assess for malabsorption problems. •Acid-neutralizing drugs (e.g., antacids) and acid-inhibiting drugs (e.g., H2-receptor blockers, proton pump inhibitors) may be given to decrease HCl acid secretion, but have little overall effect on patient outcomes. Take pc and HS. Surgery ◦Indicated when biliary disease is present, or if obstruction or pseudocyst develops ◦Diverts bile flow or relieves ductal obstruction

Chronic Renal Failure End-Stage Renal Disease (ESRD)

•Progressive, irreversible kidney injury •Risk Factors •Remember: AKI may also lead to CKD •See Table 46-9 DM: try to achieve optimal glycemic control, watch for infection HTN: ctrl with anti-hypertensives Age>60: no active prevention, but prevent any insult or kidney injury under care CV disease: risk factor reduction, often on one type of statin Family hx: teach about increased risk, do more screenings Exposure to nephrotoxic drugs: lethal to kidney tissue; limit exposure; sometimes treat with Na bicarb tx Ethnic minority: African and Native Americans higher risk; do greater screenings

Chronic Pancreatitis Complications

•Pseudocyst formation •Bile duct or duodenal obstruction •Pancreatic ascites •Pleural effusion •Pancreatic cancer

Collaborative Care: HE

•Reduce ammonia formation -Lactulose (Cephulac), which traps ammonia in gut -Rifaximin (Xifaxan) antibiotic (see Table 43-14) -Prevent constipation •Treatment of precipitating cause -? Lowering dietary protein (rarely justified) -Control GI bleeding -Remove blood from GI tract •Keep patient safe -Airway/skin protection/mouth care/care of unconscious patient -Avoid use of CNS depressants •Quiet, calm environment Table 43-11

VIRAL HEPATITIS COLLABORATIVE CARE

•Reduce fatigue •Maintain nutritional and fluid balance •Avoid alcohol •Avoid drugs detoxified by liver •Drug therapy for chronic hepatitis B (α-interferon & lamivudine) & hepatitis C (Pegylated α-interferon and ribavirin) •Most patients managed at home

Lower Urinary Tract Symptoms (LUTS) Cystitis

•See Table in textbook. •Dysuria/Burning on urination •Hesitancy/urinary dribbling or retention •Frequency/Urgency/Incontinence •Nocturia/Nocturnal enuresis •Bladder cramps or spasms •Possible hematuria/pyuria •Sediment/Cloudy/Foul smelling urine •Suprapubic pressure or discomfort •? Fever (low grade) •Usually not systemic but can develop...urosepsis Focus on Cystitis: inflammation of the bladder wall...usually do not have systemic s & s unless...has develops urosepsis Urosepsis: UTI has spread into the systemic circurculation, can be life threatening, emergency tx. •Lower urinary tract symptoms (LUTS) are experienced in patients who have UTIs of the upper urinary tracts, as well as those confined to the lower tract. • The urine may contain grossly visible blood (hematuria) or sediment, which gives it a cloudy appearance. • Symptoms are related to either bladder storage or bladder emptying. • These symptoms are defined in Table in textbook.

Clinical Manifestations: Jaundice

•Serum Bilirubin levels are about 3 mg/dl. •Nursing Care of Jaundice (icterus): •Assessment of skin, sclera & hard palate •Note color of urine (dark brown and foamy when shaken due to ↑ bili) & stool (clay colored (gray or tan)/steatorrhea due to ↓ obstructed flow of bili out of the liver) •Check serum bilirubin levels •Measures to alleviate pruritis (due to ↑ bile salts beneath skin) •Cholestyramine (Questran) or hydroxyzine (Atarax) •Baking soda or Alpha Keri baths •Lotions •Temperature control •Short nails; rub with knuckles

VIRAL HEPATITIS PATHOPHYSIOLOGY

•Similar changes for all causes of viral hepatitis •Hepatocytes affected by immune response •Specific antigen-antibody responses to different types of viral hepatitis •Liver inflammation and necrosis lead to altered function •Liver cells can regenerate over time and, if no complications occur, can resume their normal appearance and function.

Collaborative Care: Specific Treatment Measures That Might be Used to Treat a Patient's Ascites

•Sodium restriction •Albumin •Diuretics: Furosemide; Spironolactone (see Table 43-14) •Paracentesis •Transjugular intrahepatic portosystemic shunt (TIPS)

Liver disease Ambulatory and Home Care: Key Points

•Supportive measures -Proper diet -Rest -Avoidance of hepatotoxic OTC drugs -Abstinence from alcohol •Caring attitude always -Community support programs -Symptoms of complications -When to seek medical attention -Written instructions with adequate explanations for patient/family -Referral to community or home health nurse

Acute Pancreatitis Complications (Other)

•The main systemic complications of acute pancreatitis are pulmonary (pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome [ARDS]) and cardiovascular (hypotension) complications and tetany caused by hypocalcemia. •The pulmonary complications are probably due to the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels. Enzyme-induced inflammation of the diagphragm occurs with the end result being atelectasis casued by reduced diaphram movement. •Trypsin can activate thrombin and plasminogen increasing the risk for intravascular thrombi, pulmonary emboli, and DIC. •When hypocalcemia occurs, it is a sign of severe disease. It is due in part to the combining of calcium and fatty acids during fat necrosis. The exact mechanisms of how or why hypocalcemia occurs are not well understood. Patients are also at risk for developing abdominal compartment syndrome as a result of intraabdominal HTN and edema (See Chapter 43). See http://emedicine.medscape.com/article/829008-overview of abdominal compartment syndrome. Abdominal compartment syndrome can be divided into the following 3 categories: Primary or acute abdominal compartment syndrome occurs when intra-abdominal pathology is directly and proximally responsible for the compartment syndrome Secondary abdominal compartment syndrome occurs when no visible intra-abdominal injury is present but injuries outside the abdomen cause fluid accumulation Chronic abdominal compartment syndrome occurs in the presence of cirrhosis and ascites or related disease states, often in the later stages of the disease •Infection due to the inflamed and necrotic pancreatic tissue that serves as a good medium for bacterial growth. Monitor closely and use antibiotics when needed. Can develop shock.

Manifestations of Obstructed Bile Flow

•The stones may remain in the gallbladder or migrate to the cystic duct or the common bile duct. They cause pain as they pass through the ducts, and they may lodge in the ducts and produce an obstruction. Small stones are more likely to move into a duct and cause obstruction. Table 43-21 depicts the changes and manifestations that occur when the stones obstruct the common bile duct. If the blockage occurs in the cystic duct, the bile can continue to flow into the duodenum directly from the liver. However, when the bile in the gallbladder cannot escape, this stasis of bile may lead to cholecystitis. •Obstructive jaundice is caused by lack of bile flow into duodenum. •With an obstruction may also see fever and increased WBC count. Assessment for infections includes monitoring of vital signs. A temperature elevation with chills and jaundice may indicate choledocholithiasis. •If pruritus occurs with jaundice, measures to relieve itching are necessary. Measures to help alleviate pruritus include baking soda or Alpha Keri baths; applying lotions containing calamine; antihistamines; soft or old linen; and control of the temperature (not too hot and not too cold). Keep the patient's nails short and clean. Teach the patient to rub with the knuckles rather than scratch with the nails when he or she cannot resist scratching. •Common sites to observe for bleeding are the mucous membranes of the mouth, nose, gingivae, and injection sites. If injections are given, use a small-gauge needle and apply gentle pressure after the injection. Know the patient's prothrombin time and use it as a guide in the assessment process. If the patient has chronic gallbladder disease or any biliary tract obstruction, fat-soluble vitamins (A, D, E, and K) may need to be given. Bile salts may be administered to facilitate digestion and vitamin absorption. •As mentioned on previous slide, for patients with cholelithaisis provide instructions regarding observations that the patient should make that indicate obstruction (e.g., stool and urine changes, jaundice, pruritus).

Management of Esophageal Varices: Key Points

•Treatment is based on the severity of the bleeding: Monitor for BLEEDING •Ensure airway & hemodynamic stability of the patient, provide IV fluids, blood products •Banding of varices is done through EGD to stabilize vasculature. The procedure may have to be repeated several times •Sclerotherapy or shunt procedures may also be performed •Medications: octreotide, vasopressin, non-selective beta blocker, PPIs, H2 Blockers, Vit K, FFP (see Table 43-14) •Do not place NGT in patients with known or suspected varices; MD may place Blakemore tube

Urinary Tract Infection (UTI)

•UTIs common from bacterial infection (E. coli) •More common in females •Classification •Location in urinary system •Upper urinary tract (kidneys, ureters) •Lower urinary tract (bladder, urethra) •More than 100,000 people are hospitalized annually for UTIs. • More than 15% of patients who develop gram-negative bacteremia die, and one third of these cases are caused by bacterial infections originating in the urinary tract. •Escherichia coli (Table 46-1) is the most common pathogen causing a UTI, and infection occurs primarily in women. •At least 20% of women develop a UTI during their lifetime. Women have short urethras compared to men and most clinicians think the shorter urethra is the major reason women have more UTIs than men.

Bladder Cancer Diagnostic Studies

•Urine sample---exfoliated cancer cells spill over in urine •Endoscopic procedure: cystoscopy with biopsy -Care SP procedure...similar to TURP -Imaging Urine sample---exfoliated cancer cells spill over in urine Endoscopic procedure: cystoscopy with biopsy...Care SP procedure...similar to TURP see p. 1060 also and p. 1061 for biopsy care Imaging Diagnosis: Testing There are no lab tests that can specifically diagnose bladder cancer even though urine tests may suggest that cancer is present. A procedure known as cystoscopy allows visualization of the inside of the bladder through a thin, lighted tube that contains a camera. The instrument can also take small samples (biopsies) if abnormal areas are seen. The biopsy is the most reliable way to diagnose cancer. Diagnosis: Imaging Further imaging tests can be done to see how far a cancer has spread. An intravenous pyelogram is an X-ray test with contrast material to show the kidneys, ureters, and bladder. MRI and CT scans are other imaging tests that can provide more detailed images and show how far the cancer has spread. Ultrasound imaging uses sound waves to create images of internal organs http://www.medicinenet.com/bladder_cancer_pictures_slideshow/article.htm

Acute Pancreatitis Clinical Manifestations - Abdominal pain

◦Left upper quadrant or midepigastrium ◦Radiates to the back ◦Sudden onset ◦Deep, piercing, continuous or steady ◦Aggravated by eating ◦Starts when recumbent ◦Not relieved with vomiting •Abdominal pain is the predominant manifestation of acute pancreatitis. The pain is due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract. •The pain is usually located in the left upper quadrant, but it may be in the midepigastrium. •It commonly radiates to the back because of the retroperitoneal location of the pancreas. •The pain has a sudden onset and is described as severe, deep, piercing, and continuous or steady. •The pain is aggravated by eating, and frequently has its onset when the patient is recumbent. •It is not relieved by vomiting. The pain may be accompanied by flushing, cyanosis, and dyspnea. •The patient may assume various positions involving flexion of the spine in an attempt to relieve the severe pain.

Acute Pancreatitis Nursing Implementation - Ambulatory and home care

◦Physical therapy ◦Counseling regarding abstinence from alcohol, caffeine, and smoking ◦Assessment of narcotic addiction ◦Dietary teaching High-carbohydrate, with protein, low-fat diet Fat soluble vitamins may be needed ◦Patient/family teaching Signs of infection, high blood glucose, steatorrhea Medications •Loss of physical and muscle strength may need PT f/u. •Because frequent doses of opioids may be required for this patient during the acute stage, follow-up for assessment of possible opioid addiction may be indicated. This is a more likely problem with chronic pancreatitis than in the patient with acute pancreatitis. •Instruct to avoid crash dieting and bingeing because they can precipitate attacks. •Hyperglycemia and steatorrhea signs of ongoing pancreatic destruction.

Chronic Pancreatitis

◦Progressive, destructive inflammatory and fibrosing process ◦Pancreas is replaced by fibrotic tissue ◦May see strictures and calcifications in the pancreas ◦May have acute attacks •Chronic pancreatitis can be due to alcohol abuse; obstruction due to cholelithiasis (gallstones), tumor, pseudocysts, or trauma; and systemic diseases (e.g., systemic lupus erythematosus, cystic fibrosis). May or may not be related to acute pancreatitis.