Pharmacology Final- Urinary
anticholinergics with incontinence
*Oxybutynin* *Solifenacin* *Tolterodine* -decrease urgency and help alleviate pain from a neurogenic or overactive bladder -reduces muscle spasms of the bladder/ urinary tract -tend to dry out patients -*can cause confusion- don't give to older patients* -Increases constipation
alpha adrenergic antagonists
*Tamsulosin* -relax smooth muscles (in combination with antimuscarinics for men mostly) -helps urine flow better -Side effects: angioedema, orthostatic hypotension, syncopy, arrythmias
chronic symptoms of pyelonephritis
*fewer symptoms* -patients may not know -may show acute signs -fatigue, headache, poor appetite, weight loss, excessive thirst
Non-pharmaceutical management of incontinence
-*Behavioral therapy* ---effective for urge/stress/mixed ---bladder training- scheduled voiding ---normally the go-to treatment -*Pelvic muscle exercises* ---weighted vaginal cones ---stress incontinence ---important for women after giving birth ---help get stronger to hold in urine -*Timing of fluid intake*- don't drink before times that you are incontinent -*Avoiding caffeine* -*Preventing constipation*
Fluoroquinolones
-*End in "floxacin"* -Broad spectrum bactericidal -Inhibits bacterial enzymes needed for DNA replication *Food interactions*- antacids iron, milk/dairy *Drug interactions* *Adverse reactions*- achilles tendon rupture, photosensitivity, yeast infections
Creatinine
-*Normal= 0.8-1.4 in males and 0.6-1.2 in females* -waste product of skeletal muscle breakdown -accumulates when kidney can't excrete it
BUN (blood urea nitrogen)
-*Normal= 7-20 mg/dL for adults* -end waste product of protein breakdown -accumulates when the kidneys can't excrete it -checking general function of the kidneys
pyelonephritis
-*infection of the renal pelvis, tubules, tissues of the kidneys* -can be acute (enlargement of kidneys) or chronic (been infected for so long the kidneys become scarred and nephrons don't work anymore)
Prevention of UTI's
-Adequate fluid intake (flushes out microorganisms and helps maintain bladder tone) -Encourage voiding every 4 hours and right after intercourse -Perineal hygiene, wiping front to back -Avoid irritating products (bubble bath, spermicides, feminine hygiene sprays) -Good handwashing
Age-related considerations-> toddlers
-Boys potty train later than girls -Nighttime continence- 4-5 years old -*Enuresis*- bedwetting
Sulfonamides
-Broad spectrum bacteriostatic -Suppresses bacterial growth by inhibiting folic acid -Side effects: hypersensitivity, kernicterus, renal damage, hyperkalemia, teratogenic
Nitrofurantoin
-Broad spectrum bacteriostatic in low doses and bactericidal in high doses -Damages DNA -Side effects: GI effects, pulmonary reactions, peripheral neuropathy, hepatotoxicity, birth defects, CNS (HA, vertigo, drowsiness) -All will go away when medication is discontinued
Factors that influence urinary elimination- diet
-Caffeine (diuretic, irritates the bladder and makes you feel like you have to go more often) -Sodium (high sodium=less output) -Alcohol (diuretic)
Normal changes in older adults
-Decreased number of reserved nephrons -Decreased bladder muscle tone-> can't quite empty bladder and may leave urine behind (*greater risk for infection*) -Decreased bladder capacity -Weakening of muscles of the pelvic floor
conditions that contribute to UTI's
-Diabetes-> good environment for bacteria to grow, glucose may be in the urine -Pregnancy -Neurological disorders- affects the micturition reflex -Altered states
phenazopyridine
-Functions as a *local anesthetic* for the mucosa of the urinary tract -Relieves burning on urination, pain, frequency and urgency -*Usually given with an antibiotic* *Nursing considerations* -contraindicated in patients with acute kidney injury or chronic kidney disease -medication turns urine orange/red -take with food to prevent GI discomfort
How are calculi diagnosed?
-KUB (kidneys, ureter, and bladder) x-ray -Ultrasound -Retrograde pyelography- using contrast to see the function of the kidney -Blood tests (calcium, uric acid, creatinine, sodium, pH)
Diagnostic studies for the urinary system
-KUB X-ray (kidneys, ureters, bladder) -Ultrasound- can't see inside organ -CT scan -IVP (intravenous pyelogram) -Cystoscopy- direct visualization -Urodynamic testings- tests bladder muscle function (see if patient responds to increase in pressure) -disadvantage of contrast-> if they aren't having good kidney function, they can't secrete the dye Want to look at structure/functioning/positioning of organs
Structures of the urinary tract
-Kidneys -Ureters -Urinary bladder -Urethra -Prostate gland in males
Causes of UTI
-Mainly *E. coli* -Hand contamination-> not washing hands -Honeymoon cystitis (not peeing after having sex) -Urinary catheters -Incontinence
Trimethoprim
-Narrow spectrum bacteriostatic or bactericidal -Suppresses bacterial growth by inhibiting folic acid -Side effects: itching, rask, hyperkalemia, teratogenic
Age-related considerations-> infants
-Newborn-> first void *within 24 hours* -System doesn't concentrate urine effectively- *may be more watery* -Difficulty conserving fluid with dehydration *until age 2* -Child with dehydration=deadly
Urosepsis
-Potential *complication of UTI* -Spread of infection from the urinary tract to the bloodstream that results in a systemic infection -Treatment-> urine specimen for culture and sensitivity, IV antibiotics
TMZ/SMZ
-Trimethoprim/ sulfmethoxazole bactrim -Broad spectrum bacteriostatic -Suppresses bacterial growth by inhibiting folic acid -Side effects: hypersensitivity, kernicterus (build up of bilirubin), renal damage, hyperkalemia, teratogenic *generally well tolerated*
Nursing assessment of UTI's
-Visual inspection of urine-> *color, clarity, odor, blood, mucus* -Question the patient-> dysuria, burning, discharge -Urine specimens-> need an order -Physical assessment-> palpation for distention of bladder or checking for tenderness -Bladder ultrasound (need order) for residual urine after voiding
Abnormal changes in older adults
-Women have increased incontinence due to decreased levels of estrogen and weakened perineal muscles -Men-> urinary incontinence, hesitancy/difficulty starting (due to benign prostatic hypertrophy) -Decreased cardiovascular status (less profusion to the kidneys=decreased ability of the nephrons, less ability to regulate fluid)
Signs and symptoms of calculi in the *ureter*
-acute, very painful, wave-like, colicky pain -radiates down to thigh and toward the genitalia -blood in urine -desire to void, little released -can pass stones up to 1 cm in diameter
overflow incontinence
-bladder doesn't empty completely, leading to frequent urination or dribbling -bladder is full and leaks out due to *overfilling to make room for more* -caused by spinal cord injuries, urethra is blocked, tumors in the system, enlarged prostate
obstructed urinary flow causes
-congenital abnormalities -urethral structures (narrowing of the ureter) -contracture of the bladder neck -bladder tumor -calculi in the ureters or the kidneys- damages the mucosal lining -compression of the ureters
Signs and symptoms of calculi in the *renal pelvis*
-deep ache in the costo-vertebral region -blood in the urine -pyuria- pus in the urine -pain shooting from renal area to bladder -diarrhea and abdominal discomfort
Theories about calculi formation
-deficiency of substances needed to prevent crystallization in the urine -factors favor the formation of stones: dehydration, infection, urinary stasis, immobility (all contribute to increased calcium concentrations in blood
total incontinence
-doesn't respond to treatment -*completely uncontrolled and involuntary*
functional incontinence
-due to *limitations of physically getting to the bathroom and getting undressed quick enough* -can't reach the bathroom -common in older people, arthritis
Signs and Symptoms of UTI's
-frequency, urgency, nocturia -burning, pain on urination (*dysuria*) -inability to void, incomplete emptying of bladder -new incontinence -CVA or supra-pubic tenderness -cloudy, odorous urine -hematuria -fever, chills -flank pain (*pyelonephritis*) if lower UTI progresses to upper UTI -*Older adult symptoms*- confusion, change in behavior, fatigue
temporary incontinence
-happens with specific conditions or as a side effect of treatment, *usually goes away* -sleeping pills, muscle relaxants, opioids, constipation -pressure on the bladder
Urine culture techniques
-ideally should be obtained from *first void of the day and not after a recent bowel movement* -mid-stream sample recommended -Cleansing not needed unless there is a risk of labial contact with urine -most precise method= *straight catheterization* because of sterile technique -know the method used when reporting to the lab
Risk factors for UTI's
-inability or failure to empty bladder completely -immunosuppression -instrumentation of the urinary tract (cystoscopy, catheterization) -inflammation or abrasion of the urethral mucosa-> damaging the lining puts someone at risk for infection -obstructed urinary flow
botulinum toxin
-injection into detrusor muscle (botox) -used only when other medications and therapy are not successful -major limitation- post-treatment urinary retention-> botox works too well and doesn't allow the bladder to empty -used as a last line of defense
stress incontinence
-pressure on the bladder causes leaking -laughing, sneezing, coughing -due to pressure, weak pelvic muscles, weak sphincter -common in pregnant women or women who have had a baby, hormone issues
urge incontinence
-problems caused by *oversensitive bladder* -Inability to stop urine flow long enough to reach the bathroom -*overactive detrusor muscle* -paired with overactive bladder incontinence -*sudden urge with no control of bladder*
normal specific gravity concentration in urine
1.015-1.025 Low= overhydration, inability to concentrate High=dehydration, very concentrated urine, fluid loss
At what amount in the bladder does a child get the urge to void?
100-200 mL
At what amount in the bladder does an adult get the urge to void?
250-400 mL
volume/hour for catheterized patients
30 cc per hour
normal volume per void
350-400 cc
normal range of urine pH
4.6-8 depends on what the patient eats
How many cc's are normally left in the bladder after urination?
5-10 cc
How full is the bladder normally when you are able to palpate it?
600 cc
The nurse collects a urine sample from a client for urinalysis. Which of the following would the nurse document as normal? A. Light yellow in color B. Cloudy in appearance C. Presence of mucus shreds D. Ammonia odor
A
A group of nursing students are reviewing normal patterns of urinary elimination and factors that affect it. The students demonstrate an understanding of the information when they identify which of the following as a factor? Select all that apply. A. Body position B. Fluid intake C. Time of arising D. Hypertension E. Cognition
A, B, E For D-> hypotension does, not really hypertension though
At what age does the micturition reflex develop?
Around age 2-3
What type of incontinency refers to involuntary loss of urine due to *medications*? A. Overflow B. Iatrogenic C. Reflex D. Urge
B
A client is admitted to the healthcare facility with a diagnosis of stress incontinence. When reviewing the client's health record, which of the following would the nurse identify as a factor contributing to the client's condition? A. Use of diuretics B. Consumption of caffeine C. Infection of the urinary track D. Damage to the bladder neck
D
The nurse is caring for an older patient whose chart reveals that the patient has a reversible cause of urinary incontinence. The nurse creates a plan of care for which of the following condition? A. Asthma B. Decreased progesterone levels C. Bladder cancer D. Constipation
D
Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure? A. Overflow B. Urge C. Reflex D. Stress
D
Prevention of *calcium* stones
Decrease calcium intake in diet=controversial -only recommended when it is *certain* that stones are the result of excessive dietary calcium
When would you use medications for incontinence?
For patients who do not respond to behavioral therapy -Not a replacement to behavioral therapy, use WITH therapy
Why are females at greater risk for UTI?
They have a shorter urethra and is in close proximity to the rectum
True or False: pyelonephritis contributes to kidney disease
True
Factors that influence urinary elimination- infection
UTI's
hematuria
blood in the urine *Gross hematuria*- can see with the naked eye *Accoult hematuria*- microscopic Can be due to kidney damage, kidney infection, UTI's, menstruation, or stones
What are complicated UTI's normally caused by?
catheters -often recurrent, don't go away easily
Factors that influence urinary elimination- cognition
confused, incontinent because reflex is lost
Factors that influence urinary elimination- decreased muscle tone
contraction/relaxation doesn't happen, bladder fills and they can't tell
oliguria
decreased formation and excretion of urine, less than *400 cc* in one day
acute symptoms of pyelonephritis
flank pain, fevers, chills, headache, tenderness in the costal vertebral angle
Struvite stones
formed in an alkaline environment, usually in the presence of infections, foreign bodies
uric acid stones
formed in people with gout
polyuria
frequent urination, formation and excretion of excessive amounts in the *absence* of increased fluid intake -More than 2500-3000 cc in 24 hours
frequency
going more often than usual -*KEY*- not having more intake but just going more than usual, and each void is *250 cc*
Factors that influence urinary elimination- pregnancy
have to go to the bathroom frequently, uterus is right behind and above it
Factors that influence urinary elimination- psychological factors
hearing about voiding, being watched, water noises
Factors that influence urinary elimination- body positioning
how you are comfortable going (men vs women), laying for long periods of time causes retention
cystitis
inflammation of the bladder
interstitial nephritis
inflammation of the kidney
prostatitis
inflammation of the prostate
urethritis
inflammation of the ureter
suprapubic catheter
inserted directly into bladder through the abdominal wall
reflex incontinence
involuntary loss of urine without warning due to *hyperrflexia of the detrusor muscle* -usually from spinal cord injury
micturition reflex
involuntary spinal cord reflex -Bladder fills-> detrusor muscle stretches-> stretch transmitted to spinal cord-> signals detrusor muscle to contract-> stretch and pressure-> person is aware of full bladder
Factors that influence urinary elimination- obstruction of urine flow
kink along the line, catheters, stones
Factors that influence urinary elimination- hypotension
less blood flow to the kidneys, less urine output
treatment of pyelonephritis
longer and more complicated because it has to work it's way up -medications up to two weeks
mixed incontinence
mix of urge and stress -common in the general population
anuria
no urine output, less than *100 cc* in 24 hours -needs treatment immediately
BUN/creatinine ratio
normal= 10:1 dehydration= 15-20:1
urinary retention
not emptying completely, check for this with a bladder scanner *post-void*
cystine stones
occur in patients with inherited defect in the renal absorption of cystine (an amino acid)
Factors that influence urinary elimination- medications
opioids, anticholinergic medications, antihistamines
dysuria
painful urination
How does urine move down the ureters into the bladder?
peristaltic movement
pyuria
pus in the urine -often happens with UTIs -makes urine smell really bad
Factors that influence urinary elimination- neurologic injury
spinal cord injury, can't sense their bladder filling
nephrolithiasis
stones in the kidney
urolithiasis
stones in the urinary tract
Factors that influence urinary elimination- loss of body fluid
sweat, vomiting, diarrhea, burns
What is the difference between frequency and polyuria?
the amount you are putting out
urgency
the urge to go, the feeling of being unable to delay urinating -Strong micturition reflex, weak peritoneal muscles, incompetent sphincter
overactive bladder
tied together with frequency; bladder senses it is filling all the time but is *not actually full*
nocturia
waking up at night to go to the bathroom -happens with congestive heart failure -blood flow to the kidneys is increased when laying down
