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

3-14-05
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
http://www.nyu.edu/education/nursing/hartford.institute/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.
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Normal Renal Changes
Anatomical changes
•  renal vascular bed
•  renal blood flow
•  size and # of nephrons
•  size and weight of kidneys
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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
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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 &
electrolytes
• Medications - effects may last longer and may cause
aggravated interactions
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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
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Normal Bladder Changes
Physiological changes
•  bladder emptying volumes
•  bladder emptying r/t enlarged prostate
(not considered normal but high prevalence among older men)
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Normal Bladder Changes
Functional implications
•
Urgency & frequency
•
Nocturia - sleep disruption
•
Stress incontinence
•
Overflow incontinence
– in women & men (sometimes)
– in men
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Urinary Incontinence
Urinary incontinence, itself,
IS NOT a normal age-related change
• Prevalence:
1 in 3 older adults living in the
community
• Normal age-related changes, PLUS
• Drug side - effects
• UTI’s
• Conditions impairing mobility
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Urinary Incontinence
• Acute / chronic incontinence
• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Functional incontinence
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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
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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.
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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
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Urinary Incontinence
Urge incontinence
• Urinary frequency, nocturia, suprapubic
discomfort
• 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
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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
amounts
• Hesitancy, straining to void, interrupted
urine flow, occurrence day or night
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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
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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
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Urinary Tract Infections
• Contributing factors
• urinary incontinence
• loss of prostatic antibacterial secretions
• indwelling foley catheter
• hospitalization w/exposure to pathogens,
catheterization
• decline in cell-medicated immunity
• urinary retention due to BPH or anticholinergic meds
• neurogenic dysfunction, as in multiple sclerosis
• immobility
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Urinary Tract Infections
• Typical symptomatic presentation
– Dysuria, frequency, urgency
– Less common in elderly
• Atypical presentation
– more common in the frail, debilitated patient
• Asymptomatic
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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
baseline
•  respiratory rate
• Obtundation & hypotension
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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
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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:
management
therapies & behavioral
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Nursing Interventions for UI
• Indwelling catheters should not be used
routinely
• Monitor for side effect of antibiotics
• Monitor for atypical signs & symptoms in the
frail debilitated patient
• Educate patient & family on proper hygiene