Transcript Physiological basis of the care of the care of the elderly

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Your statements should be objective.
They are not narrative.
Do not add strings of thought (i.e., the
“spaghetti”) that are not directly related to
your pertinent statement.
To be a meaningful
contribution to the
patient’s care, the
statement
must be concise, clear, and….“meaty.”
The Genitourinary and Renal Systems
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D.K. is an 88 year old female who lives at
home independently
Her son brings her in stating she is
increasingly disagreeable, suspicious, and
she refuses to eat
VS: T 99.6 P 98 RR 22 BP 112/64
Normally fastidious, she is unkempt
She complains of nausea and that she cannot
control her urine
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What additional information do you need?
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Subjective information
Objective information
Psychosocial information
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WBC in CBC is 15,000
Urine culture shows 120,000 bacteria CFU
(colony forming units)
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Removal of waste
Fluid and electrolyte balance
Acid-base balance
Blood pressure
Red blood cell production
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Conserve: water
is concentrated
compared to
plasma
Rid: water is
dilute relative to
plasma
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Vasopressin (ADH) secreted by the
hypothalamus
Increases water permeability in the cell
membranes lining the water channels of the
kidneys’ collecting duct
Allows water reabsorption
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Regulation of osmolarity (amount of solute
per unit of volume)
 Sodium is major solute in extracellular fluid
 Aldosterone is secreted by renal cortex in
response to changes in osmolarity
 Aldosterone
promote
reabsorption of
sodium in the
distal nephron
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Reabsorption of bicarbonate filtered at the
glomerulus
Work in compensatory mode with lungs
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↓ in BP & filtered
Na
Kidneys release
renin
Renin converts
angiotensinogen
→ angiotensin I
Vessel
contraction
causes ↑ BP
Angiotensin II
causes vessels to
contract
ACE converts
angiotensin I into
angiotensin II
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Kidney secretes erythropoietin
Erythropoietin acts on the bone marrow to
increase red
blood cell
production
Promotes red
blood cell
survival
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Decline begins around age 40
Generally not significant until
age 90+
Decreased number of glomeruli
Decreased GFR
Decreased renal
blood flow
Decreased response
to sodium loss
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↑ susceptibility
to drug
overdose
↑ probability
of
hyperkalemia
↓ fluid intake
↑ propensity
to dehydration
↓ response to
fluid overload
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Hypertrophy of the bladder muscle
Thickening of the bladder wall
Decreased ability of the bladder to expand
Reduced storage capacity
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Testes become less firm
↓testosterone production → ↓ muscle mass and
facial & body hair
Prolonged arousal time, time before climax, and
refractory time
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Decreased/absence of ovarian function →
perimenopause and menopause
Deceased estrogen levels
◦ Less vaginal lubrication
◦ ↑ risk of urinary incontinence, infection, retention
◦ ↓ body hair, ↑ facial hair
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Changes in sexual response
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Inability to remove nitrogenous waste from
the body
Inability to regulate:
◦ Fluid
◦ Electrolytes
◦ Acid-base balance
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Acute = sudden onset,
may be reversible
Chronic = occurs over time, damage is
irreversible
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Due to decreased blood supply to kidney
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Dehydration from loss of body fluid
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Vomiting
Diarrhea
Sweating
Fever
Poor intake of fluids
Medications, e.g., diuretics
Abnormal blood flow to the kidney due to
obstruction
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Direct damage to the kidney itself
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Sepsis causing inflammation and shutdown
Medications
◦ NSAIDs
◦ Aminoglycosides
◦ Iodine-containing medications
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Rhabdomyelosis (damaged skeletal muscle
breaks down rapidly, breakdown products
can harm the kidney)
Multiple myeloma
Acute glomerulonephritis
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Due to factors affecting urine outflow
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Obstruction of bladder or ureters
Prostatic hypertrophy, cancer
Tumors of the abdomen
Kidney stones
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Diabetes
 Benign prostatic
hyperplasia
 Hypertension
 Long-term NSAID use
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Pruritis
Malaise
Generalized edema
Cognitive changes
Anorexia
Nausea
Weight loss
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Adequate fluids
 Self-awareness when new medications are
started
 Incontinence is
not normal!
 One’s normal sexual
activity level need
not change because
of advancing age
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Symptoms of UTI found in younger
population may be common in the elderly
without UTI such as urgency, frequency
 Behavioral or cognitive changes may be the
only symptom of UTI
 Asymptomatic UTI is not
treated
 Clean-catch urine for
culture is indicated in
symptomatic UTI
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New urinary urgency
Decreased flow initiation time
Voiding > 7 times in 24 hours
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Urinary frequency, urgency, dysuria
Lower abdominal pain, flank pain
Mental status changes (confusion!)
Sepsis and septic shock
Temperature >38◦C/100.4ºF
or < 36◦C/96.8ºF
Heart rate > 90 bpm
Respiratory rate > 20
WBC > 12,000 or < 4,000
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“I didn’t want to bother you, Honey!”
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Trimethoprim-sulfamethoxazole (Bactrim)
has become less effective due to resistance
Fluouroquinolones used instead
Nitrofurantoin 100 mg BID
Men require longer treatment
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Stress—weak pelvic muscles; laughing,
sneezing coughing
 Urgency—irritation of bladder
wall; UTI, BPH, tumor
 Overflow—bladder muscles
are overextended, retained
urine overflows
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Neurogenic—inability to sense
urge to void; MS,
cerebral
cortex lesions
Functional—prevented from
reaching restroom;
dementia,
disabilities, sedation,
inaccessibility
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Drugs
 Infection
 Atrophic vaginitis
 Psychological (depression, delirium,
dementia)
 Endocrine (hyperglycemia,
hypercalcemia)
 Restricted mobility
 Stool impaction
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Stress: Kegel exercises, medications, surgery
Urgency: Kegel exercises, medications,
toileting schedule
Overflow: toileting schedule, medications,
Crede method
Lifestyle modifications:
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Smoking cessation
Weight reduction
Bowel management
Caffeine reduction
Monitoring fluid intake
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Women: fecal impaction
Men: prostatic hypertrophy
Regardless of cause,
urinary retention can
lead to urinary tract
infection!
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Obstruction of the vesical neck and
compression of the urethra
Hesitancy, decreased stream, frequency,
nocturia
May produce dribbling,
poor control, overflow
incontinence and bleeding
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PSA
◦ Normal = < nanograms
◦ 4-10 nanograms = 25% chance of cancer
◦ > 10 nanograms = 50%+ chance of cancer
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Cystoscopy
Ultrasound
Intravenous pyelogram
Urodynamic studies
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Alpha-adrenergic blocking medications
◦ Tamsulosin
◦ Doxazosin
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Transurethral resections of the prostate
(TURP) if renal insufficiency, frequent UTIs,
stones, hematuria
Minimally invasive surgery for most cases
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Defined as cessation of menses
Early menopause symptoms may include
irregular periods or hot flashes
Menopause may include night sweats, sleep
difficulties, and irritability
Menopause treatments may include hormone
replacement therapy
Herbal remedies for menopause may include
soy foods and supplements
Bleeding after menopause is not normal and
likely indicates cancer
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History of abnormal Pap smears—annual Pap
smears with or without intact cervix
Hysterectomy for previous cancer—annual
Pap smears
History of normal Pap smears—annual Pap
smears until age 70
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Methods are mammography, clinical breast
exam, self breast exam
 Annual mammography for
all women over 40
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Systemic estrogen remains the most effective
treatment for relief of symptoms:
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Hot flashes and night sweats
Vaginal dryness, itching, burning
Discomfort with intercourse
Useful in preventing of the osteoporosis
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Can effectively treat vaginal symptoms
Can treat some urinary symptoms
Do not help with hot flashes, night sweats
Do not protect against osteoporosis
Low-dose vaginal preparations of estrogen
come in cream, tablet or ring form:
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Prempro (combination estrogen-progestin)
prescribed before hysterectomy carries
increased risk of
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Heart disease
Stroke
Blood clots
Breast cancer
Premarin (conjugated estrogen) prescribed
after hysterectomy
◦ No increased risk of breast cancer or heart disease
◦ Risks of stroke and blood clots were
similar to the combination therapy
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Adequate fluid intake
Acidic urine (vitamin C, cranberries, plums,
prunes)
Activity prevents stasis
Frequent toileting
Avoid catheterization
Regular examinations: annually
or every 6 months if BPH
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What is your nursing
diagnosis for DK?
What is your desired
outcome?
What are appropriate
interventions pertinent
to your desired outcome?
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