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patho ch 18
altered elmination
| Question | Answer |
|---|---|
| excreted urine | fluid content remaining after reabsorption/secretion -> enters collecting duct and move to ureter/bladder/urethra |
| renal system function | regulation of body fluid volume/composition waste elimination synthesize/release/activate hormone regulate blood pressure (RAAS) |
| what are the types of nephrons | cortical (85%) vs juxtamedullary (15%) |
| cortical nephrons | - relatively short loops of henle - main function for reabsorption/secretion - supplied by peritubular capillaries |
| juxtamedullary nephrons | - glomeruli in outer cortex and near corticomedullary junction - long loops deep into medulla which is paired with vasa recta - build/maintain medullary gradient => concentrated urine (ADH) |
| components of nephrons | - glomerulus - proximal tubule - loop of henle - distal tubule - collecting duct |
| glomerulus | network of capillaries functioning as the main filtering unit of kidneys |
| vasa recta | - hairpin shaped capillaries running along loops of henle in juxtamedullary nephrons - concentrates urine via countercurrent exchange |
| nephron role | filter blood reabsorption of filtered nutrients and water waste secretion |
| renal circulation includes | renal artery afferent/efferent arterioles peritubular capillaries glomerular capillaries vasa recta (juxtamedullary nephrons) |
| how do glomerular capillaries function | high hydrostatic pressure pushes fluid from blood into nephron @ Bowman capsule |
| steps of urine production | 1. urinary filtration 2. reabsorption 3. secretion 4. excretion as urine |
| urinary filtration (1) | - fluid pushed from blood into nephron (blood filtered at glomerulus into Bowman's Capsule) - transport via countercurrent mechanism distal to Bowman's capsule |
| Bowman's capsule | cup shaped structure surrounding glomerulus (ball of capillaries), the first site of urine production |
| Reabsorption (2) | almost all filtrate is reabsorbed into circulation |
| secretion (3) | urine secretion from circulation to filtrate |
| dark amber urine indicates | dehydration |
| cloudy urine indicates | possible infection |
| normal urine characteristics | yellow/clear w/ slight ammonia odor total daily volume 750-2000 mL |
| macroscopic urine analysis | visual inspection for color and clarity |
| biochemical urine analysis | dipstick pH, specific gravity, protein, glucose, ketone, nitrite, leuk esterase |
| microscopic urine analysis | crystals, casts, squamous cells, white/red blood cells, bacteria |
| altered urine motility | reduced contraction of hallow structure (renal tubule/ureters) |
| consequences of altered urine motility | - filtrate stasis in tubules and urine stasis in bladder - casts may form leading to risk of obstruction - ultimately altered reabsorption/secretion |
| urine casts | tube shaped structures that can form in urine --> causes obstruction |
| urinary neuromuscular dysfunction | failed/exaggerated neural signal transduction -> failure of appropriate muscle response |
| consequences of urinary neuromuscular dysfunction | limited/absent urine elimination (urinary retention/incontinence) |
| altered perfusion (renal) | inadequate blood supply (focal vs global) |
| consequences of altered perfusion (renal) | ischemia (reduced blood flow) +/- infarction (necrosis) pain |
| altered renal patency | obstruction |
| consequences of altered renal patency | blockage of urine flow dilation of structure proximal to obstruction urinary stasis -> infection renal injury |
| general clinical manifestations of altered urine elimination | altered excretory volume/characteristics bleeding pain/distension anorexia nausea/vomiting/fever |
| dx of altered elimination | macro/microscopic urine analysis GFR and Cr clearance rates imaging (IV pyelogram, renal angiogram, renal US) |
| tx of altered elimination | fluid administration in deficit use of diuretics in excess |
| processes of stool elimination | blood supply via superior/inferior mesenteric arteries autonomic nervous system innervation |
| large intestine components | cecum appendix colon rectum anal canal |
| colon divisions | ascending transverse descending sigmoid |
| transport of fecal matter | peristalsis via segmental vs mass movement |
| where does fecal matter enter colon | ileocecal valve into cecum |
| stool evacuation via | rectal sphincter relaxation |
| efferent impulse inhibition vs stimulation | inhibition = constriction of anal sphincter stimulation = relaxation of anal sphincter |
| neural impulse for fecal evacuation | distended rectum -> afferent impulse signaling -> sacral spinal cord -> cerebral cortex -> defecation |
| stool composition | - 25-50g solids + 100 mL water - unabsorbed nutrient, sloughed epithelial cells, bile pigment, bacteria, - 10-20% fats, 30% undigested dietary fiber, 20% inorganic solids |
| normal stool characteristics | brown pigmentation due to stercobilin reflecting diet varying volume/frequency soft/moist/semisolid |
| stercobilin | bile pigment |
| stool analysis | elimination patterns (bowel movements) characteristics (color, consistency, volume, shape, odor) |
| altered bowel motility | altered water/vitamin absorption altered storage time obstruction risk |
| consequence of altered bowel motility | constipation vs diarrhea |
| altered bowel perfusion | global vs focal perfusion |
| consequences of altered bowel perfusion | ischemia (reduced blood flow) +/- infarction (necrosis) pain |
| patency | state of being unobstructed |
| altered bowel patency | obstruction via tumor vs impaction |
| consequences of altered bowel patency | distension impaired motility perforation |
| general clinical manifestations of altered bowel elimination | altered stool volume/characteristics bleeding (melena vs occult) pain/distension anorexia/nausea/vomiting fever |
| diarrhea indicates | possible inflammation (ie Crohns/UC) infection fast transit dysfunction of H2O reabsorption |
| constipation indicates | slow transit obstruction low fiber/fluid diet opioid use voluntary stool holding (behavioral) |
| how to guestimate location of partial bowel obstruction | wetter stool = obstruction is closer to cecum/ascending colon drier stool = obstruction more distal (more water absorption possible |
| blood color patterns | bright red = hemorrhoids/fissure/fistula black tar (melena) = upper GI bleed maroon = mid GI source (ie diverticular) occult = invisible |
| pale/clay colored stool indicates | little/no bile reaching intestine indicative of liver/GB/bile duct issue |
| fatty/foul/floating stool indicates | fat malabsorption (steatorrhea) |
| stringy stool indicates | seen in parasitic infections |
| diagnosis for altered elimination | stool characteristic imaging studies endoscopic (sigmoidoscopy vs colonoscopy) |
| treatments for altered elimination | treat underlying cause - fluid/electrolyte correction - infection/inflammation - obstruction relief - prevention of reoccurrence |
| appendicitis | inflammation/obstruction of appendiceal lumen McBurney's point + referred pain |
| urolithiasis pathophysiology | renal calculi/stones derived from solid masses precipitated in filtrate causes urinary stasis + elevated urine salt or organic/inorganic acids possible tubule obstruction |
| urolithiasis clinical manifestations | renal colic pain vs non colic pain |
| renal colic pain | distension of collection system/ureter acute, intermittent, radiating, excruciating |
| non renal colic pain | distension of renal calices/pelvis dull/deep pain with varying intensity |
| dx of urolithiasis | pain Hx imaging study urinalysis + analysis of calculi composition |
| tx for urolithiasis | - pharmacologic (pain control) - calculi removal (fluid intake, reduction of calculi size, surgical removal) - prevention w/ dietary modification |
| urinary incontinence pathophysiology | inability to prevent urine discharge |
| causes of urinary incontinence | impaired muscle contraction vs altered neural transmission hormonal stimulation mechanical factor |
| clinical manifestation of urinary incontinence | - exertational stimuli (stress) - overactivity of detrusor muscle - exceeding bladder capacity - inability to independently toilet |
| types of urinary incontinence | - stress incontinence - urge incontinence (OAB) - overflow incontinence - functional incontinence |
| dx for urinary incontinence | H&P specialized testing (post residual bladder volume and urodynamic testing) cystoscopy |
| tx for urinary incontinence | - bladder training/pelvic floor strengthening - pharmacologic (anticholinergics or alpha-adrenergic medications) - surgical intervention (for obstruction) |
| polycystic kidney disease pathophysiology | growth of fluid filled renal cysts B/L replacement of functional tissue with reduced perfusion and tubule obstruction |
| categories of PKD | genetic - autosomal dominant (AD) vs recessive (AR) acquired |
| clinical manifestations of PKD | enlarged kidneys HTN (from altered renal fn) flank pain altered fluid/electrolyte balance renal calculi (diverticular disease) urinary tract infections |
| organ involvement in PKD | liver and pancreas can develop cysts cardiac valvular disease cerebral aneurysms |
| dx of PKD | FHx + genetic testing physical exam (HTN) imaging (3 or more renal cysts on US; extrarenal cysts) lab confirmation of renal failure |
| tx of PKD | - symptomatic care (pain + infection + BP control) - promotion of renal function (dialysis or transplant) |
| intestinal diverticular disease pathophysiology | - prolonged pressure on large intestinal walls causing wall weakness -> intestinal wall outpouching |
| consequences of intestinal diverticular disease | - decreased motility - obstruction - impaired perfusion |
| classification of diverticular disease | diverticulum (small outpouching sac) diverticula (more than 1 diverticulum) diverticulitis (infected diverticula d/t fecal matter) |
| clinical manifestations of diverticular disease | abdominal pain fever nausea vomiting |
| dx of diverticular disease | H+P (abdominal tenderness and distension) lab analysis (bloody stool, low H/H, abnormal CBC) imaging (inflamed/ruptured diverticula) |
| prevention of diverticular disease | dietary and lifestyle modification pharmacologic -- bulk forming laxatives + antispasmodics |
| tx of diverticular disease | symptom management infection control bowel rest complication prevention surgical correction of perforated diverticula |
| functional fecal incontinence pathophysiology | repetitive/involuntary stool passage in children 4 and up retentive incontinence vs nonretentive |
| developmental triggers of functional fecal incontinence | introduction of solid foods toilet training starting school attendance |
| retentive stool incontinence | retentive posturing excessive volitional stool retention Hx hard/painful BM large fecal mass/large diameter stools in rectum |
| nonretentive stool incontinence | socially inappropriate defecation absence of organic dz absence of excessive stool/fecal retention at least once monthly occurring for minimum 2 months |
| dx for functional stool incontinence | History pattern, related factor, diet Hx, emotional stress, associated symptoms Physical exam - R/O organic cause |
| tx for functional stool incontinence | - behavioral management (toilet refusal, scheduled toileting, incentives) - constipation prevention - counseling |
Created by:
sleepingbear