Full transcript
0:04this is gu disorders part one uh this is
0:07going to cover neurogenic bladder kidney
0:09stones and urinary diversions
0:13so first is neurogenic bladder again
0:16noro medical root word noro means
0:18neurological system nervous system genic
0:21means creation of so this is something
0:23wrong with the bladder the bladder is
0:24not working because of the nervous
0:26system
0:27it's bladder dysfunction that results
0:29from some kind of a neurological problem
0:31it could be a stroke diabetes it could
0:34be parkinson's multiple sclerosis spinal
0:37cord injury
0:40and so there's something
0:42neurologically wrong um where the
0:44neurological system isn't sensing that
0:47the bladder's filling or the
0:48neurological system is not telling the
0:50bladder to go ahead and empty
0:53there are two types
0:55[ __ ] bladder and flaccid bladder two
0:58different types of neurogenic bladder
1:01um depending on the pathology that's
1:03going on
1:04uh [ __ ] bladder you think about that
1:07detrusor muscle that surrounds the
1:08bladder what's happening with [ __ ]
1:10bladder is that trucer muscle is
1:12contracting on reflex
1:15there's nothing
1:16telling it to do so the bladder is not
1:18even necessarily full yet but for one
1:20reason or another that detrusor muscle
1:22contracts it squeezes all the urine out
1:25and as a result the person ends up
1:26having this reflex incontinence
1:29the other is flaccid bladder
1:32where the bladder fills without the
1:34neurological system even sensing that
1:36the bladder is full
1:37it doesn't know that it's full it gets
1:40over distended the hydrostatic pressure
1:42increases
1:43and next thing you know the person is
1:44having overflow incontinence remember
1:46with overflow incontinence that's always
1:48associated with urinary retention
1:52so those are the two types as far as
1:54complications
1:56you're thinking about this urine um
1:58that's sitting in there longer than what
2:00it should be brewing festering
2:02um you know letting the minerals
2:04congregate to other uh to each other um
2:07so it can lead to things like infection
2:10um because the bacteria is starting to
2:12grow in that urine you've got a warm
2:14moist dark environment microorganisms
2:16like those kind of places and so next
2:18thing you know they start to populate
2:20and there's a urinary tract infection it
2:23could lead to urolithiasis
2:25urine means urinary system litho means
2:28stones isis is formation of creation of
2:32so it's creation of kidney stones
2:34basically
2:35again your urine you've got all these
2:37minerals that are being filtered out by
2:39the kidneys just sitting in there
2:40brewing festering if they're sitting
2:42around
2:44longer than what they really should be
2:45your body's not getting rid of that
2:47what's going to happen all those
2:49minerals are going to start to find each
2:50other start to crystallize and form
2:52kidney stones
2:54um it can lead to
2:56uh reflex where the body the water that
2:59the fluid the urine actually starts to
3:00back up into the orders up into the
3:02kidneys and cause hydronephrosis which
3:05can cause some kidney damage
3:07which can eventually lead to kidney
3:09failure
3:11all of these things from a neurogenic
3:13bladder
3:14as far as management it depends on what
3:16type of neurogenic bladder the person's
3:19experiencing how they're going to be
3:21managed
3:24it could involve intermittent
3:26self-catheterization remember when the
3:28client is catheterizing himself when
3:30we're teaching him to catheterize
3:31himself we don't have to teach them
3:33sterile technique
3:35they're using their own
3:37they're exposing themselves to their own
3:38microorganisms you know on their body in
3:41their environment in their home and so
3:43therefore we only have to teach them
3:45clean technique we give them some
3:48clean straight catheters
3:51we teach them how to catheterize
3:52themselves when you're done using your
3:53catheter just wash it with some warm
3:55soapy water set it out to dry use it
3:57again the next time you have to empty
3:58your bladder
4:01potentially
4:02could teach them to
4:04go on a low calcium diet
4:07if in fact they're forming
4:09calcium-related kidney stones we're
4:10going to talk about kidney stones later
4:12calcium is one of those causative
4:14factors that leads to kidney stones
4:17however what i want you to understand
4:18with this and you're going to hear me
4:20say this again
4:21in a few minutes from now when we get to
4:23kidney stones you should only restrict
4:26the calcium in the diet if it's
4:27excessive
4:30otherwise the body has mechanisms in
4:31place
4:32to try to raise the calcium level
4:37and so you're going to be
4:38counterproductive
4:40so only if the calcium intake is
4:41excessive should they limit their
4:43calcium intake
4:44liberal fluid intake
4:47to try to really flesh out the kidneys
4:50prevent any stasis of urine which could
4:52lead to infection
4:54keep the urine diluted so it doesn't
4:55have a chance to crystallize and form
4:57kidney stones
4:58so we encourage lots of fluids
5:02if they have [ __ ] bladder
5:05and we want to relax that detrucer
5:07muscle then we want to bring out the
5:09effects of the sympathetic nervous
5:12system if you remember this from
5:13pharmacology
5:14so we can give anticholinergics reduce
5:17the effects of the parasympathetic
5:18nervous system to bring out the effects
5:19of the sympathetic nervous system
5:21to help to relax the detrucer muscle
5:24this would be used
5:25to treat that [ __ ] bladder
5:28when the tone of the detrusor muscle is
5:30really tight and it contracts on reflex
5:33you want to relax it so we can give
5:35anti-cholinergics
5:37we could also give anti-spasmodics
5:40again to try to take down the spasms of
5:42the bladder
5:43so this is your ditropan your detrill
5:46those are the medicines we would get
5:48prescribed for [ __ ]
5:50bladder just the opposite if the client
5:53has a flaccid bladder
5:55the tone of the detrusor muscle is
5:57really weak and we want to increase the
5:59tone of the juicer muscle so it can
6:01contract and push the urine out so it
6:03doesn't overfill then we would want to
6:06bring up the effects of the
6:07parasympathetic nervous system therefore
6:10we would get them cholinergic
6:11medications this is bethanicola
6:14urocholine we talked about this one in
6:16pharmacology as well
6:18and those are used to treat flaccid
6:20bladder to try to increase the tone of
6:21the juice or muscle
6:23so two different categories of
6:25medicines to treat the two different
6:27types
6:28of neurogenic bladder make sure you
6:30understand that
6:31we could also put the client on a
6:33bladder retraining program to try to
6:34help we can put them on a timed
6:37voiding schedule
6:38[Music]
6:40where we encourage the person to go into
6:42the bathroom void
6:44empty your bladder and then we're using
6:46the clock and say i want you to be able
6:48to try to hold your urine in as best as
6:51you can
6:52um and you start slow you say for 45
6:55minutes i want you to to squeeze
6:58hold your bladder as best as you can and
7:00then the 45 minutes then go to the
7:02bathroom and empty your bladder and try
7:04to hold it for another 45 minutes and
7:06then slowly over time you extend that
7:07time until they're able to hold their
7:09urine you know for two to three hours
7:12so that's what timed voiding is
7:14prompt avoiding is knowing the times
7:17physiologically that your body likes to
7:19try to empty its platter we're going to
7:21time your your your bathroom visits to
7:24try to maximize that as much as possible
7:27so after you've gotten up first thing in
7:29the morning
7:31after you've had anything to eat or
7:32drink at bedtime you know those times we
7:36just prompt you to go into the bathroom
7:37and try to empty your bladder whether
7:38you feel like you need to or not try to
7:40get your bladder emptied as best as
7:42possible so that you're minimizing
7:45episodes of incontinence that might
7:46occur
7:48double voiding if they're having lots of
7:50retention issues remember a
7:54urinary retention of less than 50 is
7:56normal if you or i go to the bathroom
7:58and empty our bladders it's not
8:00necessarily completely empty that
8:01there's zero milliliters of urine in the
8:03bladder there can be up to 50
8:04milliliters still in the bladder we
8:07don't worry about it until it gets up to
8:08around 200 milliliters that we consider
8:10that to be excessive urinary retention
8:12and start to put interventions in place
8:14uh to treat that
8:16so to try to help with that excess of
8:18urinary retention which goes along again
8:21with that flaccid bladder
8:23we encourage the client to go to the
8:24bathroom sit on the toilet stay on the
8:27toilet
8:28for five minutes and then try to go
8:30again
8:31that double voiding
8:33and then other the other intervention
8:36would be kegel exercises this kind of
8:38goes along earlier with the time voiding
8:40that i mentioned
8:41where you're encouraging the person to
8:42do some isometric exercises of those
8:47pelvic floor muscles
8:50to try to strengthen those up to help to
8:52regain
8:53control
8:54so it doesn't have a chance to leak out
8:57without my control of it
8:59so you encourage them to sit usually how
9:02we do this encourage them to sit on some
9:04kind of a firm surface where you can
9:05kind of feel what's going on underneath
9:07you squeeze those pelvic floor muscles
9:10until you feel your anus lift up off the
9:13chair
9:14squeeze and hold that for about 10
9:16seconds and then relax and do it again
9:19and do it again and do it again
9:21that's kegel exercise is to try to
9:23increase
9:25those muscles uh to gain control the
9:28other way to teach kegel exercises is as
9:31the person is voiding
9:34they want to squeeze those pelvic floor
9:36muscles and kind of pinch off the gear
9:37and stream
9:38hold it for a few seconds and then relax
9:42let the urine flow again and then pinch
9:44and stop the flow again
9:46um
9:47to try to gain control over the urinary
9:49flow better so those are examples of
9:51kegel exercises and we would try to
9:53teach those to help the person to regain
9:55control of the urine flow
9:58next is urolithiasis nephrolithiasis
10:01kidney stones urinary stones stones
10:04like i already mentioned
10:05this happens whenever those minerals in
10:07the urine have a chance to crystallize
10:09with each other and form stones in the
10:12urinary system
10:16it can involve three different um
10:20mechanisms
10:21that lead to
10:22kidney stone formation it could be just
10:24slow urine flow again where you've got
10:26this retention
10:28that urine sitting around having a
10:29chance for those minerals to crystallize
10:32with each other and forming stones for
10:33that way
10:35it can be because of damage that's been
10:37done to the urinary tract
10:40once again may alter the flow
10:42cause some retention
10:45you know promoting urinary retention so
10:47it could be because of damage or it
10:49could be because of a decrease in some
10:52of the inhibitor substances that your
10:54body has in place naturally anyways to
10:56try to prevent the crystallization of
10:58those minerals
11:01again stones normally form because of
11:03high concentration
11:04of one of these minerals
11:06most commonly calcium about 80 percent
11:09of urinary stones are calcium based it
11:12is by far and large the most common
11:14type of kidney stone
11:16so from having just excess of calcium
11:18that the kidneys are responsible for
11:19filtering out that's going to lead to
11:23increased likelihood of developing
11:24urinary stones
11:26it could also be because of having too
11:29much phosphate it could be because of
11:31having too much uric acid
11:33leading to urad stones um so we'll be
11:36talking about all these um
11:38they can form anywhere in the urinary
11:40system anywhere from the nephrons all
11:42the way down to the urethra
11:46so it can form anywhere and they can be
11:49any size as far as the sizes go as long
11:52as the kidney stone is less than five
11:54millimeters in size
11:57they normally will treat that
11:58conservatively and let it pass naturally
12:02you know just with increased fluids and
12:04nsaids and anti-spasmodics let the
12:07kidney stone pass naturally whenever it
12:09starts to increase in size now is when
12:11they start to do some interventions
12:13once the kidney stone gets to be about
12:15five to ten millimeters in size only
12:17about twenty percent of those will pass
12:20naturally and by the time the kidney
12:22stone is greater than 10 millimeters in
12:24size they will rarely pass without any
12:27kind of treatment or intervention
12:29so the size is really important
12:34again as far as the types let me go
12:35through those individually you see those
12:37listed
12:38the first is calcium phosphate
12:41again calcium
12:43based it can be because of having an
12:45increased calcium intake like i
12:46mentioned earlier but let's say that you
12:49actually have a calcium deficiency in
12:52your your diet um the endocrine system
12:56has your parathyroid glands your
12:57parathyroid glands are responsible for
12:59producing parathyroid hormone parathor
13:01moon we'll talk about that again when we
13:03get to endocrine system and what the
13:06excuse me parathyroid gland does
13:09is it releases parathyroid hormone which
13:11is responsible for intentionally raising
13:14the serum calcium level when it's too
13:16low it does that by sucking calcium
13:19right out of the bones what we call
13:21calcium resorption
13:23sucking it right out of the bones
13:24putting it in the bloodstream to raise
13:26the calcium level
13:27which again that's why
13:29you don't want to decrease calcium
13:31intake unless it's excessive to begin
13:33with because if now you make the person
13:35calcium deficient
13:37parathyroid hormone is going to kick in
13:39it's going to raise the calcium intake
13:41by sucking it right out of the bones and
13:43cause a problem
13:45so it could be because of increased
13:47parathyroid hormone um you know maybe
13:50there's a tumor in the parathyroid
13:52glands that's causing increased
13:54secretion of parathyroid hormone and
13:56that's what's causing the calcium
13:57phosphate stone
13:58it could be because of increasing
14:01or excess of vitamin d intake maybe the
14:04person supplementing vitamin d because
14:07he wants to boost his immune system
14:09doesn't want to get sick so he's taking
14:11lots of supplements of vitamin d and as
14:13a result absorbing through the
14:15intestinal tract
14:16more
14:17calcium that's leading to calcium stones
14:20so about five percent of kidney stones
14:22are calcium phosphate
14:25and then calcium oxalate
14:28makes up about eighty 80 of your stones
14:30so you can see you know collectively
14:32calcium makes up almost all your kidney
14:35stones it's it's the most
14:37um causative factor of your kidney
14:39stones um calcium oxalate comes from
14:42diet
14:44so again excess of calcium intake as
14:46well as
14:47excess of oxalate intake and that comes
14:50from things like spinach chocolate
14:52strawberries
14:53black tea peanuts sweet potatoes
14:57these all contain oxalate
15:00so again if your person's drinking lots
15:02of black tea and getting kidney stones
15:05you may have to talk to him about
15:06limiting his oxalate intake and switch
15:09from black tea
15:10to drinking something else instead
15:13urate stones obviously are formed by
15:15uric acid
15:17uric acid is normally in the body to
15:19begin with the kidneys filter that out
15:22um
15:23and so from having excess of uric acid
15:25that comes from excessive
15:28protein metabolism we'll talk about that
15:31later as well when we talk about gout
15:34later this semester and so urate stones
15:36form about five percent of your kidney
15:38stones
15:39the next type there are struvite stones
15:42this comes from somebody who has very
15:44frequent urinary infections
15:47that can lead to struvite stones
15:49that makes up about 10 percent of the
15:52kidney stones and in the last which is
15:54more rare this makes up
15:56only about one percent of kidney stones
15:58this is cystine stones
16:01and that comes from an inherited genetic
16:03condition
16:04leads to cystine stones
16:06also keep in mind just like when we
16:08talked about anemia the person can have
16:10more than one
16:12type of kidney stone concurrently
16:15maybe he's got frequent urinary tract
16:18infections as well as excess of calcium
16:20intake and so he can have multiple
16:23reasons for having kidney stones it may
16:25not always be just
16:26one
16:31as far as a location
16:34i'll talk about that real quick again um
16:38they can form anywhere in the urinary
16:40system
16:40but the location
16:42is directly related to the symptoms the
16:44person is going to experience
16:46if he has a kidney stone
16:49very high up in his urinary system if
16:53it's up in the renal calyx if it's in
16:55the proximal
16:57ureter and it's causing some irritation
17:00up there it's obstructing up there the
17:02person's going to experience some flank
17:04tenderness what we call cva tenderness
17:07costo vertebral angle tenderness
17:10to test that you see that depicted in
17:13the bottom right graphic there where you
17:16put your hand over top of their cva
17:18their costo vertebral angle costa means
17:21ribs
17:22v vertebrae so where the ribs and the
17:24vertebrae come together
17:26that's where you put your palm and then
17:28you tap it if they experience
17:31excruciating pain whenever you do that
17:34and they have that flank tenderness
17:36then you know that their kidney stone is
17:38located in the upper part of the renal
17:41system however if that kidney stone has
17:44migrated and moved
17:46and it's lodged itself it's irritated
17:48the ureter in the lower the distal part
17:50of the order or the bladder they will
17:53not have any cva tenderness they will
17:55have no flank tenderness
17:57at all that's very often misleading
18:00to students and to nurses
18:02if they have a kidney stone that's
18:04irritating or obstructing the lower part
18:06of the renal system where that person
18:08will experience his pain and his
18:11tenderness
18:12it refers and they'll actually feel it
18:15down in their thigh or their groin area
18:18they will tell you i don't know what's
18:19going on but my right testicle has just
18:21been aching and hurting and it comes and
18:23goes and i don't know what's going on or
18:26they'll tell you that their thigh hurts
18:28or their groin hurts um
18:30that very well may be a kidney stone
18:32that's in the distal part of the ureter
18:36or the bladder or the urethra so keep
18:38that in mind like i said that's directly
18:40related to the location
18:42i already talked about the size is very
18:45important
18:46less than five millimeters usually pass
18:48naturally they will the doctor
18:51will allow that to pass with just
18:52conservative treatment and the bigger it
18:55the stone is the more likely the person
18:57will require interventions to remove the
18:59stone
19:00as far as risk factors men are three
19:03times more likely to get kidney stones
19:05than our women
19:06a history of having a kidney stone is a
19:09major risk factor
19:11people who've had a history of having a
19:13kidney stone about 50 of those will
19:15experience another kidney stone within
19:17five years because like i already
19:19mentioned when i talked about the types
19:20of stones a lot of these require some
19:22kind of lifestyle modification to
19:25prevent the formation of stones
19:27so if they've had a history of stoves
19:29they're more likely to have another
19:30stone unless they make some lifestyle
19:31changes
19:33so that serves as a major risk factor
19:36a lot of them are unknown um don't
19:38really know why their kidney stone has
19:40formed
19:41um
19:42but again we're going to encourage some
19:44lifestyle modifications to try to
19:46prevent that dehydration serves as a
19:48risk factor
19:50because the um
19:54the minerals and the uric acid and all
19:56those substances in the urine are
19:59allowed to become more concentrated if
20:02the person's dehydrated there's less
20:03dilution so that allows the the
20:05formation of kidney stones
20:07if you have a deficiency of one of those
20:10preventative factors like i mentioned
20:12earlier that allow the crystallization
20:15in the urine things like citrate
20:18glycoprotein inhibitors
20:20that can lead to kidney stone formation
20:24family history doubles your risk of
20:26having a kidney stone hypertension
20:28actually doubles your chance of having a
20:30kidney stone
20:31increased physical exercise especially
20:34you know endurance training like
20:35marathon running
20:37again because of the increased
20:39concentration of the urine that
20:41increased crystal urea that's going to
20:43lead to increased kidney stone formation
20:46frequent infections in the urinary
20:48system like i already mentioned will
20:49lead to an increase in those struvite
20:51stones
20:52immobility because of the urinary
20:54retention
20:56hypercalcemia
20:58already talked about that
20:59um
21:00excess of uric acid like with gout
21:06the genetic factors
21:09hereditary factors leading to cysteine
21:11stones
21:12it could be because of an anatomic
21:14abnormality
21:15leading to and promoting some urinary
21:18retention we already talked about how
21:20urinary retention
21:21increases the likelihood of stone
21:23formation
21:25inflammatory bowel disease
21:29you know like crevices
21:31that we talked about last week um
21:34a colon resection ileostomies um
21:37actually cause more absorption of
21:39oxalates that can lead to calcium
21:41oxalate stones
21:42um frequent antacids and again thinking
21:46back to gi system if they've got lots of
21:48gerd lots of gastritis
21:50so they're taking lots of antacids all
21:52on their own over the counter a lot of
21:54those
21:55contain a lot of calcium so that excess
21:58of calcium intake from the antacids can
22:01lead to
22:02kidney stone formation
22:06excess of vitamin d i already talked
22:08about
22:08laxatives aspirin
22:11um
22:13diuretics
22:14except for thiazide diuretics
22:18diuretics can cause volume depletion and
22:20actually promote the formation of kidney
22:22stones so diuretics except for thiazides
22:26can increase the likelihood of calcium
22:27i'm sorry of kidney stones as well
22:31so lots of risk factors to consider
22:34as far as manifestations
22:36as many as 70 of your clients will be
22:38asymptomatic
22:40that they have a kidney stone however
22:42what to keep in mind is even though they
22:44may be asymptomatic some kidney damage
22:47some nephron damage may be occurring at
22:49the same time without their awareness
22:51that it's even occurring
22:53the most common symptom the gold
22:55standard symptom would be that colic
22:57pain that renal colic that um
23:00you know crampy severe sharp pain that
23:02comes and goes
23:04that however typically only occurs
23:08whenever they've the stone itself is
23:10migrating and moving or obstructing
23:14so that is the most common symptom like
23:16i said they may associate that cva
23:18tenderness the flank pain but again
23:20that's only if it's lodged in the upper
23:22part of the renal system
23:24they may experience referred pain down
23:28in the the testicle the the groin the
23:30labia
23:32down in that area if the kidney stone
23:35is
23:36migrating moving causing inflammation or
23:38obstructing in the lower part
23:40of the
23:41renal system the urinary system
23:44the pain is most intense whenever it's
23:47migrating when it's ever whenever it's
23:49moving
23:50that incidentally is also when it causes
23:53some hematuria again that's a symptom
23:55that a lot of people readily associate
23:58with having a kidney stone
23:59is experiencing some pink tinge urine
24:02some hematuria but they don't always
24:04have that they usually only have the
24:06hematuria when the stone is moving when
24:08it's migrating if it's kind of lodged
24:10and stuck in place it typically doesn't
24:13result in hematuria
24:15they may not detect any hematuria at all
24:18in about 30 percent of cases it
24:20increases with production i'm sorry
24:22progression of the stone as it's moving
24:24migrating
24:25day one of migration as it starts to
24:27move
24:29about 95 percent of patients will
24:31experience some hematuria some pig
24:33tinged urine
24:34by about day three after the migration
24:37only about 60 percent of clients will
24:39still experience any kind of hematuria
24:42and like i said after that they may not
24:45experience any hematuria
24:47so the hematuria that people often
24:49associate with kidney stones usually
24:51only occurs when it's moving and
24:52migrating
24:54um
24:54other symptoms now if it the stone is
24:58causing an obstruction
25:00and leading to some hydronephrosis
25:03that's when they start to get some of
25:05the systemic symptoms as well and
25:07they'll start to get some nausea some
25:09vomiting anxiety diaphoresis tachycardia
25:14elevated blood pressure
25:18severe severe anxiety
25:21those other symptoms typically occur
25:23whenever there's some kind of
25:25obstruction occurring and it's leading
25:26to some hydronephrosis that's when they
25:29start to get nauseous and vomiting and
25:31and those other symptoms
25:33it can lead to some possible bladder
25:38obstruction where they can't get the
25:40urine out um
25:43you know some
25:45some disc areas some painful urination
25:48that's common and again with obstruction
25:51it can lead to some oligaria where they
25:54have decreased urinary output remember
25:55the normal is at least 30 milliliters an
25:58hour if they're experiencing less than
26:0030 milliliters of urinary output
26:03there could be some kind of pathology
26:04going on
26:06as far as labs and diagnostics
26:09initially a kidney stone is suspected
26:11just by clinical presentation alone
26:14enough of the symptoms make you suspect
26:15they have a kidney stone
26:17but when it comes to labs and
26:18diagnostics the gold standard is your ct
26:22scheme scan
26:24and you see that right in the center of
26:25the screen i have that bolded and
26:27starred for you
26:28so you'd want to put a star next to that
26:30in your notes as well
26:31the
26:33abdominal ct scan is your gold standard
26:36diagnostic tool
26:37for kidney stones
26:39the non-contrast is the most sensitive
26:41test for this
26:42this is the test of choice um the reason
26:46is not only does it show where the
26:48kidney stone is but it is this that
26:51allows them to determine the size of the
26:53kidney stone
26:54and a simple x-ray a kub an abdominal
26:57plate
26:58incidentally will show kidney stones
27:02they're usually picked up incidentally
27:03on an x-ray but it's not diagnostic um
27:07because they can't um actually measure
27:10the kidney stone that to see how how
27:12large it is and remember the size
27:14directly dictates how they're going to
27:16treat it
27:17and they can't do that with an x-ray
27:18remember an x-ray is nothing more than a
27:20shadow so this there is some distortion
27:21of size
27:22for that reason
27:24the other thing to keep in mind
27:26with your x-ray a simple kub
27:29is
27:29urate stones are translucent radiolucent
27:33they don't show up at all
27:35on a simple x-ray
27:37so you wouldn't be able to determine
27:38those
27:40urinalysis
27:42can be diagnostic
27:44remember what a urinalysis shows what it
27:46doesn't show so if the client's starting
27:48to have some red blood cells in
27:50urinalysis some white blood cells in
27:51your analysis they actually start to see
27:54increased crystallization
27:56um
27:57the change in ph on the urinalysis those
28:00could all be indicative that the person
28:02has a urinary stone the cbc again may
28:05show
28:07some of the systemic symptoms of having
28:10a kidney stone like an elevated white
28:11blood cell count
28:14might make you realize the person has
28:16something going on in the urinary system
28:18especially when you group that together
28:19with other symptoms a person's
28:20experiencing
28:22um on blood tests again having an
28:24elevated calcium level phosphorus level
28:27uric acid level
28:28those may be grouped together with other
28:31symptoms to make you
28:33realize diagnostically that the person
28:35has a kidney stone
28:37a urogram
28:39where they're actually injecting some
28:42radio opaque dye
28:44and taking some pictures
28:46um
28:47to be able to
28:50pick up on the stones pick up on the
28:51obstruction
28:53you can see the picture on the right is
28:55showing a retrograde pilogram where they
28:58actually go into
29:00the order they inject some radio opaque
29:02dye
29:03and then take pictures of it
29:06and you can actually see the stones
29:07showing up there i have that circled for
29:09you
29:10so that's a retrograde pilogram
29:15renal ultrasound
29:17you can use ultrasound
29:19to show some of the stones the advantage
29:20here is there's no
29:22[Music]
29:24radiation involved so this is a good
29:26option as well as mri
29:28for somebody who is pregnant or can't
29:30take the radiation
29:32um
29:33laboratory analysis of the stone is
29:36essential
29:37in order to determine the type of stone
29:39which of those five types of stones
29:42has this person actually produced so you
29:44need to have a urinary analysis of the
29:46stone itself so the important
29:48intervention here is to strain all the
29:50urine to catch the stone get it sent
29:51down to the lab so they can actually
29:53determine what type of stone
29:56which will help them dictate the
29:57treatment
29:5824-hour urine tests
30:01can be useful as well
30:03remember with the 24-hour urine test
30:05that begins
30:06with the first void you mark the time
30:09and then you collect all urines for the
30:11next 24 hours if a urine is missed then
30:14you have to throw it away and start over
30:17potential complications again could
30:19involve urinary obstruction
30:21infection could lead to urosepsis which
30:23is potentially life-threatening and it
30:26can lead to acute kidney failure because
30:28of the obstruction
30:30as far as management i actually talked
30:32about several of these as i was talking
30:34earlier as far as from a nursing
30:36standpoint again good assessment to find
30:39out if the person has any of those risk
30:41factors
30:43family history history of having a
30:45kidney stone do you over exercise do you
30:48drink adequate fluids
30:50all of that
30:52assessment strategies a good dietary
30:55history is your ex is your calcium
30:58intake excessive is your oxalate intake
31:01excessive are you drinking enough water
31:04all those kind of things um
31:06if they have a history you really want
31:08to encourage and increase fluid intake
31:11so remember normal is two liters a day
31:14that's what i would like to encourage
31:16all of my patients to have so i would
31:18encourage them to have more than two
31:21liters a day
31:22which is what would be encouraged
31:25getting a good medication history you
31:27know are you on diuretics do you have a
31:29history of high blood pressure you know
31:31some of those risk factors assessing for
31:33bladder distension you know feeling
31:35above
31:36the pubic bone to actually feel that
31:39they've got some of that urinary
31:40retention in there
31:42um
31:44doing a
31:46bladder scan using the ultrasound to see
31:48whether or not they have some urinary
31:50retention
31:51monitor their vital signs
31:54to see if they're having symptoms of of
31:55pain
31:58a chemical analysis
32:00um
32:01again straining the urine to find out
32:03what type of stone they're actually
32:05having
32:06monitoring for the pattern of pain and
32:08again they'll have that increasing pain
32:10whenever the stone is actually migrating
32:12and moving or when it's obstructing if
32:14it's obstructing they'll have a lot of
32:16those systemic symptoms the nausea the
32:18vomiting the diuresis diaphoresis sorry
32:21the tachycardia those kind of things
32:23as far as patient teaching
32:26they should reporting any decrease in
32:29urine any hematuria they're experiencing
32:31any increasing in pain
32:33any fever
32:34if they're having any of the symptoms of
32:36having a complication
32:39um you know such as an obstruction
32:41you're monitoring for those
32:43procedures
32:45for the treatment you have to
32:47give them some patient teaching related
32:49to that
32:50patient teaching related to pain control
32:52again encouraging them to report any
32:54increase in pain that may signal an
32:57obstruction that may signal that it's
32:58actually migrating and moving which
33:00could lead to an obstruction
33:02remember that
33:03that ureter gets more narrow it's funnel
33:05shaped it gets more narrow as it as it
33:08progresses as it gets more distal as it
33:10works its way towards the the bladder
33:12and so if the stone is moving then it
33:14has an increased likelihood it could
33:15lead to an obstruction so encourage the
33:17patient to to report that increasing
33:19pain
33:20um
33:22educate the patient that you do need to
33:24strain all the urine so we can actually
33:26test the urine and see what type of
33:28stone you have
33:29increasing fluid intake um again at
33:32least more than two liters a day more
33:34than the minimal we'd like to really
33:36push fluids though and get that up to
33:37three liters if we could
33:40dietary restrictions if applicable i've
33:42already talked about that
33:43monitoring i know
33:45hot baths can help with some of the
33:46urinary spasms they may be experiencing
33:49to help out with pain
33:51nutrition
33:53depends on the type of stone and again
33:54that'll be determined once they've
33:56strained the stone and got that sent to
33:58the lab to determine what type of stone
34:00it is
34:01if it's a calcium stone again don't
34:04restrict dietary calcium unless it's
34:06already been excessive that'll lead to
34:08increased parathyroid hormone increase
34:11bone
34:12calcium leaching we want to minimize
34:14that
34:15restricting protein
34:17and sodium
34:18which actually increases
34:20calcium
34:21deposits
34:23ammonium chloride may be used that helps
34:26to acidify the urine to prevent the
34:28crystallization of the calcium stones
34:30thiazide diuretics can be used if again
34:34the person has excess of parathyroid
34:36hormone
34:37they can use
34:39thiazidics to minimize some of that to
34:41minimize the formation of calcium stones
34:44if they've got calcium oxalate stones
34:48then we avoid you know some of those
34:49foods that have oxalate like i already
34:51mentioned avoid spinach strawberries
34:54rhubarb chocolate black tea peanuts
34:57sweet potatoes grapes celery wheat bran
35:01green peppers
35:03any of those oxalate type things make
35:05sure you're aware of that
35:07if they have a urea stone that comes
35:09from uric acid
35:11then we put them on a low purine diet
35:13which we're going to talk about again
35:14when we talk about gout
35:16which basically comes from high protein
35:18intake so avoid
35:21high protein foods
35:23avoid organ meats avoid eating lots of
35:26protein
35:27avoid lots of fish
35:30as well as asparagus mushrooms
35:33low purines
35:35and aloe purenol
35:37can be used to try to help with the uric
35:40acid levels in the body
35:42serum uric acid level should be less
35:44than six and we'll talk about that again
35:46um so if the serum uric acid level is
35:49excessive we want to minimize
35:52urine uric acid formation
35:55which means we put them on a low purine
35:56diet
35:58cystine stones
36:00we would put them on a low
36:02protein diet to try to help to alkalize
36:05the urine
36:06and then struvite stones again come from
36:09frequent urinary tract infections so as
36:12far as patient teaching we would just do
36:14whatever we can to minimize their
36:17likelihood of
36:18developing urinary tract infections
36:24as far as medical management drug
36:26therapy
36:27aimed at pain control
36:29again that's typically needed whenever
36:31that's known as migrating or moving or
36:34obstructing
36:35um
36:35[Music]
36:36for rapid relief
36:38we can use opioids we can use toradol
36:44those are good options
36:46most patients are treated conservatively
36:49when it comes to pain management and
36:51hydration just increasing fluids giving
36:54them nsaids
36:55nsaids actually help to decrease some of
36:58that smooth muscle tone decrease the
37:00ureteral spasms decrease the pain and
37:02studies actually suggest that nsaids are
37:04just as effective as opioids for pain
37:07control when it comes to kidney stones
37:10the problem is these hurt like really
37:12bad and so when it comes to patient
37:15satisfaction the patient probably is not
37:17going to be satisfied with his
37:18prescriber his doctor if all the doctor
37:21gives him is an nsaid so for that reason
37:23the doctors very frequently will
37:24prescribe opioids
37:26for
37:28kidney stones even though the research
37:29shows they may not actually be necessary
37:32but like i already mentioned stones that
37:34are less than five millimeters in size
37:36are probably going to be permitted to to
37:38pass naturally
37:39with increased hydration you know
37:41pushing fluids in nsaids alone most of
37:44them will pass that way naturally
37:45anyways uh some antispasmodics some
37:48spasmolytic drugs can be used to try to
37:51take away some of the spasms in the
37:53urinary system this is your ditropan
37:56your um
37:57praban theme ura spaz
38:00these are all examples of spasmolytic
38:02drugs
38:04calcium channel blockers are very
38:06effective
38:07um
38:08your procardia alpha blockers are very
38:12common and very effective this is your
38:14tamsillosing your flomax that you may
38:16see
38:18a client ordered
38:20to try to help with some of the the
38:21muscle tone
38:23of the urinary system to increase the
38:25rate of passage um
38:27calcium channel blockers and alpha
38:29blockers actually help to increase the
38:31rate of passage by about 65
38:33so again conservative treatment very
38:35common um
38:37to try to help that pass that stone to
38:39pass naturally is pushing fluids give
38:41them nsaids and give them either a
38:43calcium channel blocker or an alpha
38:45blocker i already talked about nsaids i
38:48already talked about the use of thiazide
38:50diuretics or allopyranol
38:53if it's a urinary i'm sorry if it's a
38:55uric acid stone
38:58as far as lithotripsy
39:00extracorporeal shockwave lithotripsy is
39:03using sound waves to break up that stone
39:06this is the treatment of choice in 75
39:09percent of patients when that stone is
39:11too large to pass naturally so again
39:13once it gets up around 10 millimeters in
39:15size you can expect them to do
39:17lithotripsy to break up the stone make
39:19it smaller fragments
39:21this works best for stones that are that
39:24are located proximally you know up in
39:27the renal pelvis the upper ureters and
39:29again the larger stones once they're up
39:30around 10 millimeters in size you can
39:33expect them to do lithotripsy break it
39:35up into smaller uh fragments that will
39:38then pass naturally with increased
39:40fluids and seds
39:43alpha blockers those conservative
39:45treatments
39:46this is done under moderate sedation um
39:50because it is invasive and said will be
39:52held for three days before the
39:54lithotripsy is done
39:58you can expect the person to
40:00experiencing some bruising of his flank
40:03when he returns to you that's a
40:04completely normal expected finding so
40:07don't be surprised if your patient comes
40:09back from having his lift the tripsy gun
40:11and he has a big bruise on his flank i'm
40:13not getting concerned and doing jumping
40:15jacks over that like i already mentioned
40:17we want to make sure afterwards that
40:19we're encouraging fluids um
40:21giving him boluses of iv fluids to
40:23really flush
40:24that kidney system out and get all those
40:26stone fragments out and we want to make
40:28sure that we're straining all of the
40:30urine to catch all those stone fragments
40:33it may require more than one treatment
40:35so don't be surprised if your person has
40:38to go back for multiple lithotripsy
40:40treatments before they finally get it
40:42all out
40:45there's a picture of the
40:47shockwave lithotripsy what they actually
40:50do
40:51as far as surgical management
40:53we'll talk about a couple things here
40:56they can go in
40:57and place a stent in the urinary system
41:00which is just kind of like a wire mesh
41:02that expands and helps to
41:05increase the lumen of the ureter to help
41:07to hold it open so that the stones don't
41:09have a chance to get caught
41:11um
41:12it actually you know helps to kind of
41:14dilate
41:15the ureter
41:16to prevent the the obstruction
41:19that can help with obstruction some of
41:21the systemic symptoms the the pain that
41:24comes from
41:25the migration and the obstruction the
41:27bleeding so they can place a stent
41:29that's done with a ureteroscope you see
41:32that picture there on the left
41:34also
41:35during euroscopy
41:37they can go in you know they go right up
41:39the
41:40um this is not under sedation they go in
41:42uh to the urethra up through the bladder
41:44and up into one of the ureters
41:46and they can either place the stent or
41:49like you see on the bottom right there
41:51they can use a basket to actually grab a
41:53hold of the stone and pull it out remove
41:56it that way
41:57um
41:59so with the ureteroscope they can
42:01actually
42:03remove the stone itself
42:06and the other thing they can do i think
42:08i have a satellite for this
42:10is percutaneous
42:12go through
42:13the skin go through the flank right into
42:16the kidney
42:17and
42:19remove some of the stones break up the
42:21stones that way
42:23a needle is passed into that renal calyx
42:26and the stones are removed that way they
42:28can use
42:30lithotripsy if it is a large stone to
42:32break it up and then remove the
42:34fragments
42:35percutaneously
42:37they do frequently place a nephrostomy
42:39tube after this procedure has been done
42:42so don't be surprised when your patient
42:44comes back with the nephrostomy tube in
42:46place you want to make sure obviously
42:48that you're monitoring that nephrostomy
42:50tube
42:51you're looking at the insertion site
42:52keeping it from getting infected you're
42:54making sure there's no drainage coming
42:56out around the nephrostomy tube it will
42:58have a transparent drainage i'm sorry
43:00transparent transparent dressing over
43:03top of the insertion site that you can
43:04monitor that and see that you're
43:06monitoring the output that's coming
43:08through the nephrostomy tube
43:10you're irrigating that nephrostomy too
43:13because again there may be stone
43:14fragments that may be draining you don't
43:16want them to get
43:18lodged in that nephrostomy tube and
43:20block it so you do
43:23irrigate these as far as the arrogant
43:26obviously sterile technique
43:28you push the irrigant in very slowly not
43:31very forcefully this is going right into
43:33the center of their kidney you don't
43:34want to damage their kidney
43:36so very gently you put the saline in and
43:39then you
43:40disconnect the syringe and you attach it
43:42to the drainage
43:44collection device the bag and let it
43:46drain out naturally you don't create
43:48negative pressure by drawing back on the
43:50syringe you never want to do that that
43:52negative pressure that suction can cause
43:54damage to the kidney so you don't want
43:56to do that
43:58placing the
44:00nephrostomy tube and doing the
44:01percutaneous procedure can also lead to
44:04some hemorrhage so you're watching for
44:06that complication as well we've talked
44:07about that before
44:09it could actually lead to pneumothorax
44:11with a punctured lung
44:13believe it or not so you want to monitor
44:15for that as well and we've talked about
44:16that before
44:18again they've just done a
44:21invasive procedure you know poking
44:23directly into the kidney so don't be
44:26surprised if within the first 48 hours
44:29there is some bloody drainage coming
44:31through that nephrostomy tube that's
44:33completely normal expected if however
44:35there's bloody drainage coming through
44:37that nephrostomy tube after the first
44:39couple days that is concerning i'm doing
44:41jumping jacks and getting concerned and
44:43calling the doctor over that
44:47they can also do open surgical
44:48procedures this is rarely done
44:51it's only when other procedures have
44:52been ineffective and haven't worked
44:55they could do an open surgical procedure
44:57where they actually go in
45:01open up the abdomen
45:05if they need to
45:06remove this stone a very large stone an
45:08obstructing stone
45:10a stag horton kidney
45:12they can fix that way or if they need to
45:14correct any anatomical abnormalities
45:16that may be going on
45:18they're going to give some broad
45:19spectrum antibiotics
45:21to try to prevent any infection that may
45:23be occurring because again that's a high
45:25likelihood
45:27with those procedures
45:30and there is
45:31an increased likelihood of obstruction
45:32so again you want to make sure that
45:34you're measuring the intake and output
45:37monitoring the fluid increasing fluid
45:39intake all that kind of stuff
45:43as far as urinary diversions
45:46this is where they're diverting they're
45:47redirecting the urinary flow through a
45:50new site through a new opening
45:52for one reason or another
45:55it can be because of a birth defect
45:57malignancy strictures obstructions
46:00neurogenic bladder
46:03you know chronic infections
46:05but for one reason or another they may
46:07create different urinary diversions
46:10there are different types of urinary
46:12diversions
46:14cutaneous which means skin
46:17what you need to understand with the
46:18cutaneous diversions is these all
46:20require the use of a collection bag that
46:22will be used to collect the urine
46:24and then another type is continent
46:27diversions
46:29where the person is allowed to maintain
46:32some type of continence
46:34which means he may be required to
46:37catheterize the new stoma that they've
46:38created to go in to that area where the
46:41urine is collecting and catheterize it
46:44to drain it
46:45it allows him to maintain some kind of
46:46continence but these all require
46:48catheterization
46:50the last one that you see listed there
46:52is kind of its own category a urinary
46:55sigmoid ostomy
46:58so urinary means the orders sigmoid is
47:01your sigmoid colon and ostomy they're
47:03creating a new opening so basically what
47:06they're doing is they're connecting the
47:07orders
47:08to
47:09from the urinary system to the sigmoid
47:11part of the colon the gi system and
47:14allowing the rectum to be used as the
47:17reservoir so again the person's allowed
47:19to maintain subcontinence by holding the
47:20urine in his rectum and then the urine
47:23passes through his rectum with his bowel
47:25movements
47:27so each of these quickly individually
47:30the suprapubic catheter again cutaneous
47:33where the catheter is actually placed
47:35directly through the abdominal wall into
47:37the bladder
47:38using a collection bag to
47:41collect the urine that way
47:43an ileal conduit where the orders are
47:46attached to a small section of an ilium
47:49the ilium is removed and used as a stoma
47:54to connect the ureters from the urinary
47:56system to the abdominal wall
47:58and then it drains into a collection bag
48:00that's attached to their abdominal wall
48:02now on the right in red letters you can
48:04see this this is important to understand
48:06any time
48:08that the surgeon is using a section of
48:10bowel to create a urinary diversion
48:13remember your bowel system naturally
48:16produces mucus
48:18that's that's natural so don't be
48:21surprised it's completely common
48:22completely normal for their urine if
48:25they've had a section of bowel used in
48:27the diversion for the urine to contain
48:29some mucus that's a normal assessment
48:31finding
48:32not getting concerned about that at all
48:35a urter ostomy
48:38they're taking the ureter and creating a
48:40new opening in the abdominal wall
48:43from that so the ureter is attached
48:45directly to the abdominal wall a
48:46collection bag is attached to the above
48:48the wall to collect the urine that's
48:49draining
48:50that way
48:51a vesicotomy
48:54just like with the suprapubic catheter
48:58there's a stoma that's created directly
49:00through the bladder and there's a
49:03collection bag there that collects the
49:05urine
49:06a nephrostomy again an opening is
49:09created directly into the renal calyx
49:12and the nephrons and the urine is
49:13allowed to drain directly from there and
49:17this involves the use of a collection
49:18bag the catheter is inserted directly
49:20into that renal pelvis
49:22so these all involve the use of a
49:24collection bag
49:26which you see there
49:28again if they're using a section of
49:30bowel to create that diversion don't be
49:32surprised if the urine is coming out
49:33with some mucous in it as well
49:36and then we've got the continent
49:37diversions where the person is allowed
49:39to maintain some continence and again
49:41these
49:43involve a catheterization the stone is
49:45created that the person can catheterize
49:48remember as far as the catheterization
49:52he doesn't have
49:55neurological sensation that this new
49:58[Music]
50:00diversion this new collection
50:03area in the body that's been created is
50:05filling up with urine so he's not going
50:06to feel oh you know that that's filling
50:08up i need to urinate
50:10because the neurological system isn't
50:12really telling him that this um
50:16reservoir is is filling up with urine so
50:18he needs to on a timed basis make sure
50:20he knows every couple hours oh it's time
50:22to go in and catheterize myself
50:25to maintain that continence
50:27so we've got some different examples
50:28there the indiana pouch the coke pouch
50:31the charleston pouch
50:33where again they're using sections of
50:35bowel with the charleston pouch they're
50:37using actually the appendix itself
50:39itself
50:40to create that stoma and then
50:43these areas and create reservoirs that
50:46are catheterized
50:47again because they're using section of
50:49bowel for all these expect there to be
50:51some mucus there's going to be no
50:53sensation of filling so they need to
50:55just go in and catheterize themselves
50:59on a timed basis
51:02um the last one
51:03gotero sigmoidostomy already mentioned
51:06those this one the orders are attached
51:09directly to the sigmoid colon and using
51:11the rectum as a reservoir the urine
51:14flows out of the rectum
51:17as far as potential post-op
51:18complications of these procedures
51:20atelectasis and pneumonia again
51:23atelectasis collapsing of the lung
51:25tissue
51:26the best intervention for atelectasis is
51:29your incentive spirometer
51:34other interventions for both of these
51:36atelectasis and pneumonia you know
51:38encouraging them to elevate the head of
51:39the bed cough and deep breathe get up
51:42and ambulate so all of those
51:44interventions would be would be
51:45important to minimize the risk of
51:47adelectosis and pneumonia keep in mind
51:49the symptoms of atelectasis and ammonia
51:52that you're watching for to know when
51:53maybe my patient is experiencing a
51:56complication of his surgical procedure
51:58that he just had
51:59fluid electrolyte imbalances could occur
52:02sepsis severe infection could occur so
52:05you're monitoring for that fistula
52:07formation a new communication
52:10between two areas of the body that
52:12normally don't communicate with each
52:13other could
52:16develop you know through the healing
52:18process so
52:20um that is a complication to be aware of
52:22it could lead to a breakdown
52:24of those anastomoses those two things
52:26that they've attached to each other
52:29maybe they break down maybe they weren't
52:30attached completely
52:32and so that could lead to some leaking
52:34of either urinary or bowel
52:37contents into the abdominal cavity which
52:39could lead to peritonitis and we've
52:42talked about that a couple times already
52:44so watch for those symptoms of
52:45peritonitis remember the telltale
52:47symptom is that rebound tenderness that
52:49blumberg sign as well as the loss of
52:52bowel sounds the ascites
52:55the real rigid firm
52:57board like abdomen the pain that
53:00radiates up into the neck shoulder jaw
53:03so keep in mind all of those symptoms of
53:04pair tonight is that i'm observing and
53:06watching for
53:07uh the stoma itself i'm making sure i'm
53:10watching it it should be nice and pink
53:12it should be elevated it should be
53:14attached to the abdominal wall
53:16it shouldn't be pulled and separated it
53:18shouldn't be turning dark and dusky and
53:20gray and purple and brown
53:23that is
53:24unexpected any of those symptoms that i
53:26just mentioned you want to make sure
53:28that you call the surgeon immediately
53:30for any of those things if it starts to
53:32retract separate
53:34turn dark
53:36you need to call the surgeon immediately
53:39and there could be some skin irritation
53:41around the stoma so you're making sure
53:43that you're watching the skin around the
53:45stoma to make sure it's not getting
53:46irritated and we're doing whatever we
53:48can to protect that skin you know
53:50because it is coming in contact with
53:52urine
53:53and so we want to protect that skin
53:56so that's everything for part one
53:59of the gu lecture
54:01as always if you have any questions
54:03issues with anything please contact me
54:05let me know
54:06and then
54:07make sure to listen to part two of the
54:10gu lecture