3-14-05 Aging & the Renal / Urinary System Content for this module provided by: • The John A.

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Transcript 3-14-05 Aging & the Renal / Urinary System Content for this module provided by: • The John A.

Aging & the Renal /
Urinary System
Content for this module provided by:
• The John A. Hartford Foundation, Institute for Geriatric Nursing,
Online Gerontological Nursing Certification Review Course
Support for this project provided to School of Nursing, University of
Washington by the John A. Hartford Foundation, Geriatric Nursing
Education Grant and Nursing School Geriatric Investment Program Grant.
Normal Renal Changes
Anatomical changes
•  renal vascular bed
•  renal blood flow
•  size and # of nephrons
•  size and weight of kidneys
Normal Renal Changes
Physiological changes
•  GFR,  function of loop of Henle and tubules
•  capacity for maintaining Na+ & K+ balance,
acid/base balance
•  reserve capacity for homeostasis of osmotic
pressure & blood pressure
•  ability to produce erythropoietin to regulate
oxygen levels
Normal Renal Changes
Functional considerations
• Adequate function unless acute illness and/or
comorbidities exist
•  renal clearance of acids, urea, uric acid, creatinine,
toxins, & certain medications
•  adaptive responses: with acute illness, watch fluid &
• Medications - effects may last longer and may cause
aggravated interactions
Normal Bladder Changes
Anatomical changes
• Weakening bladder & pelvic muscles
•  bladder capacity
•  bladder contractions
• Thinning of urethral mucosa r/t  estrogen
•  urethral resistance r/t  muscle tone & bulk
•  sensory receptors
Normal Bladder Changes
Physiological changes
•  bladder emptying volumes
•  bladder emptying r/t enlarged prostate
(not considered normal but high prevalence among older men)
Normal Bladder Changes
Functional implications
Urgency & frequency
Nocturia - sleep disruption
Stress incontinence
Overflow incontinence
– in women & men (sometimes)
– in men
Urinary Incontinence
Urinary incontinence, itself,
IS NOT a normal age-related change
• Prevalence:
1 in 3 older adults living in the
• Normal age-related changes, PLUS
• Drug side - effects
• UTI’s
• Conditions impairing mobility
Urinary Incontinence
• Acute / chronic incontinence
• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Functional incontinence
Urinary Incontinence
• Acute incontinence (sudden onset)
• Generally associated medical/surgical condition
• Resolves when underlying cause is corrected
• Any new onset of incontinence should be considered
acute, with possible precipitating causes ruled out
• Medications should always be suspect
• Chronic incontinence
• Continues over time, often becoming worse
Drug Induced Incontinence
• Urinary retention
– anticholinergic agents & agents w/anticholinergic effects
– smooth muscle relaxants
– -agonists
• Stress
– -antagonists
• Urge
– polyuria: diuretics, lithium
– central inhibition: narcoleptics
• Secondary
– benzodiazepines, sedative-hypnotics
*Owens NJ, Sillman RA, Fretwell, MD. (1989). The relationship between comprehensive functional assessment
and optimal pharmacotherapy in the older patient. DICP: the annals of pharmacotherapy, 23, 847-854.
Urinary Incontinence
Stress incontinence
• Often seen in older women
•relating to uterine or pelvic prolapse**
• In men, related to sphincter weakness after
prostatectomy due to reanastomosis of urethra to
bladder, removal of prostatic urethra
• Involuntary loss of urine as the result of sudden increase
in intraabdominal pressure
•coughing, sneezing, laughing
•lifting, exercise, changing position
**May result from pregnancy, vaginal delivery, trauma
during gynecologic/urologic surgery, obesity, chronic coughing
Urinary Incontinence
Urge incontinence
• Urinary frequency, nocturia, suprapubic
• Associated with:
• CNS disorders, such as Parkinson’s and stroke,
• Bladder disorders, such as bladder cancer, cancer
treatment, or bladder outlet obstruction
• Urgency & involuntary loss can be precipitated
by sound of running water, cold weather, or site
of toilet
Urinary Incontinence
Overflow incontinence
• Leakage of urine without the urge to void,
usually resulting from a distended or
obstructed bladder
• Frequent, involuntary urine loss of small
• Hesitancy, straining to void, interrupted
urine flow, occurrence day or night
Urinary Incontinence
Functional incontinence
• Occurs as a result of inability or unwillingness
to toilet appropriately
• physical (i.e. gait problems)
• mental (i.e. cognitive impairment)
• psychologic (i.e. severe depression)
• environmental factors (i.e. acute, long term care settings)
• Should be a diagnosis of exclusion - careful
assessment may identify treatable factors
Urinary Tract Infections
• Most common cause of bacterial sepsis in
older adults
• Gram-negative bacteria that original normally
in GI tract
• 10 times more common in women
– female anatomy
Urinary Tract Infections
• Contributing factors
• urinary incontinence
• loss of prostatic antibacterial secretions
• indwelling foley catheter
• hospitalization w/exposure to pathogens,
• decline in cell-medicated immunity
• urinary retention due to BPH or anticholinergic meds
• neurogenic dysfunction, as in multiple sclerosis
• immobility
Urinary Tract Infections
• Typical symptomatic presentation
– Dysuria, frequency, urgency
– Less common in elderly
• Atypical presentation
– more common in the frail, debilitated patient
• Asymptomatic
Urinary Tract Infections
• Atypical presentation
• New onset incontinence (particularly in females)
• Mental status changes , including confusion,
disorientation, agitation
• Lethargy, nausea, vomiting, & abdominal pain
• Delayed/low grade fever, or temp +/- 2 degrees from
•  respiratory rate
• Obtundation & hypotension
Urinary Tract Infections
• Asymptomatic
• UTI found arbitrarily on exam
• Generally, should not be treated unless patient has
neurogenic bladder, obstructive uropathy, or other
obstructive disorders
Nursing Interventions for UI
• Assess for transient causes that can be
eliminated or reduced (i.e., functional etiologies)
• Encourage fluid intake, if not contraindicated
• Skin care in genital areas
• Patient education:
therapies & behavioral
Nursing Interventions for UI
• Indwelling catheters should not be used
• Monitor for side effect of antibiotics
• Monitor for atypical signs & symptoms in the
frail debilitated patient
• Educate patient & family on proper hygiene