WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.030 fast. Welcome to the emergency room. Welcome 00:00:47.030 --> 00:00:51.630 back to the Deep Dive. Our mission today is really 00:00:51.630 --> 00:00:53.750 laser focused and I think vital for a lot of 00:00:53.750 --> 00:00:56.289 you. We know you're gearing up for one of the 00:00:56.289 --> 00:00:59.159 toughest sections of the MedSurg exam. renal 00:00:59.159 --> 00:01:02.020 and urologic disorders. So instead of trying 00:01:02.020 --> 00:01:04.120 to boil the ocean and cover everything, we're 00:01:04.120 --> 00:01:06.400 going with the Pareto principle. We're going 00:01:06.400 --> 00:01:10.040 to dive deep into that critical 20 % of information, 00:01:10.500 --> 00:01:13.159 the high yield stuff. That's going to give you 00:01:13.159 --> 00:01:15.280 80 % of the understanding you need. That's exactly 00:01:15.280 --> 00:01:17.760 right. And this isn't about just memorizing a 00:01:17.760 --> 00:01:20.280 bunch of random facts. It's about really understanding 00:01:20.280 --> 00:01:22.480 the why behind the disease, and more importantly, 00:01:22.579 --> 00:01:25.359 what your nursing response has to be. Our sources 00:01:25.359 --> 00:01:27.879 today really give us an intensive breakdown of 00:01:27.879 --> 00:01:29.879 the big issues. We're talking infections that 00:01:29.879 --> 00:01:32.359 can go septic, like UTIs and pyelonephritis. 00:01:32.640 --> 00:01:34.840 Then there are the immunologic problems that 00:01:34.840 --> 00:01:36.879 mess with fluid balance, like glomerulonephritis 00:01:36.879 --> 00:01:40.180 and nephrotic syndrome. And then you've got the... 00:01:40.409 --> 00:01:43.010 Well, the mechanical nightmares like kidney stones 00:01:43.010 --> 00:01:45.230 and the functional issues like incontinence. 00:01:45.530 --> 00:01:47.709 And to really guide this deep dive, we're setting 00:01:47.709 --> 00:01:52.049 up three, let's call them non -negotiable overarching 00:01:52.049 --> 00:01:54.810 nursing priorities. These apply to almost everything 00:01:54.810 --> 00:01:57.209 we're gonna talk about today. So as you study, 00:01:57.670 --> 00:01:59.969 for every single condition, you should be asking 00:01:59.969 --> 00:02:03.390 yourself, one, does this cause a massive fluid 00:02:03.390 --> 00:02:07.430 balance shift? Two, does it require urgent pain 00:02:07.430 --> 00:02:11.020 control? And three, is there an immediate life 00:02:11.020 --> 00:02:14.060 -threatening sepsis risk? Exactly. If you can 00:02:14.060 --> 00:02:15.979 answer those three questions for each of these 00:02:15.979 --> 00:02:18.439 diseases, you're already building that foundational 00:02:18.439 --> 00:02:20.539 knowledge you need, not just for the exam, but 00:02:20.539 --> 00:02:23.020 for the bedside. So let's unpack this. Let's 00:02:23.020 --> 00:02:24.780 do it. All right, we have to start with the most 00:02:24.780 --> 00:02:27.120 common urologic infection, the urinary tract 00:02:27.120 --> 00:02:29.759 infection. I think it's one of those things that 00:02:29.759 --> 00:02:32.960 can seem almost mundane, but the potential for 00:02:32.960 --> 00:02:34.659 it to become a systemic illness is huge, right? 00:02:34.659 --> 00:02:38.289 It is, especially in certain populations. So 00:02:38.289 --> 00:02:40.009 to kick things off, let's talk about the basic 00:02:40.009 --> 00:02:42.289 defenses that have to fail for a UTI to even 00:02:42.289 --> 00:02:44.889 begin. So let's break down the pathophysiology. 00:02:45.469 --> 00:02:47.789 The system above your urethra, so the bladder, 00:02:47.990 --> 00:02:50.909 the ureters, the kidneys, that whole area is 00:02:50.909 --> 00:02:53.849 inherently sterile. And nature has given us two 00:02:53.849 --> 00:02:56.789 main defenses to keep it that way. First, you've 00:02:56.789 --> 00:02:59.449 got the acidic pH of the urine. It's usually 00:02:59.449 --> 00:03:02.870 somewhere between 4 and 7 .5, and most bacteria 00:03:02.870 --> 00:03:05.419 just can't grow in that environment. OK, so it's 00:03:05.419 --> 00:03:08.060 hostile territory for germs. Exactly. And the 00:03:08.060 --> 00:03:10.539 second defense is purely mechanical. It's the 00:03:10.539 --> 00:03:12.780 flushing action of urination. Every time you 00:03:12.780 --> 00:03:15.960 void, you're physically washing out any bacteria 00:03:15.960 --> 00:03:18.080 that might be trying to creep up the urethra. 00:03:18.259 --> 00:03:21.080 So a UTI happens when a pathogen gets past those 00:03:21.080 --> 00:03:24.129 defenses. Precisely. And overwhelmingly, in like 00:03:24.129 --> 00:03:26.909 75 % of cases that don't involve some kind of 00:03:26.909 --> 00:03:29.689 structural defect, that pathogen is E. coli. 00:03:29.789 --> 00:03:32.490 It ascends from the perineal area, gets into 00:03:32.490 --> 00:03:34.990 the bladder, and it overcomes those defenses, 00:03:35.289 --> 00:03:37.449 usually because the bladder isn't emptying completely. 00:03:37.650 --> 00:03:39.770 And that failure, that's what leads to cystitis, 00:03:39.870 --> 00:03:42.250 the bladder infection. But I think the key here 00:03:42.250 --> 00:03:45.789 for testing is identifying the risk factors that 00:03:45.789 --> 00:03:48.750 set the stage for that to happen. Yeah, and they 00:03:48.750 --> 00:03:51.939 fall into three really critical categories. First 00:03:51.939 --> 00:03:54.840 is anything that compromises the immune response. 00:03:55.300 --> 00:03:58.120 So think about aging patients, people with poorly 00:03:58.120 --> 00:04:00.919 controlled diabetes. Because the sugar in the 00:04:00.919 --> 00:04:03.400 urine feeds the bacteria. Right, it's fuel for 00:04:03.400 --> 00:04:06.900 them, exactly. Or anyone on immunosuppressive 00:04:06.900 --> 00:04:08.939 drugs. That's bucket number one. OK, and the 00:04:08.939 --> 00:04:11.580 second? The second is anything that causes urinary 00:04:11.580 --> 00:04:14.039 stasis. I mean, if the bladder doesn't empty 00:04:14.039 --> 00:04:15.960 all the way, those bacteria just sit there and 00:04:15.960 --> 00:04:17.980 multiply. They're not getting flushed out. So 00:04:17.980 --> 00:04:21.360 that would be things like BPH in men. BPH is 00:04:21.360 --> 00:04:24.379 a classic example. Or urethral strictures, a 00:04:24.379 --> 00:04:26.500 neurogenic bladder from a spinal cord injury, 00:04:27.100 --> 00:04:29.220 anything that obstructs the outflow. And then 00:04:29.220 --> 00:04:30.720 there's the third category. And this is the one 00:04:30.720 --> 00:04:33.120 where, I mean, nursing intervention is just absolutely 00:04:33.120 --> 00:04:34.660 paramount. It is. We're talking about foreign 00:04:34.660 --> 00:04:37.639 bodies. Indwelling catheters. Indwelling catheters. 00:04:38.519 --> 00:04:41.500 CIUT's catheter -associated urinary tract infections 00:04:41.500 --> 00:04:43.839 are the single biggest source of health care 00:04:43.839 --> 00:04:47.399 -associated UTIs. Full stop. The sources are 00:04:47.399 --> 00:04:50.420 so clear on this. The catheter itself, even with 00:04:50.420 --> 00:04:53.600 perfect sterile technique, bypasses all the natural 00:04:53.600 --> 00:04:56.360 defenses. And gives the bacteria a highway right 00:04:56.360 --> 00:04:58.660 into the bladder. A highway and a... place to 00:04:58.660 --> 00:05:01.600 live. It provides a surface for biofilm to develop. 00:05:02.160 --> 00:05:04.439 So preventing CI -UTI isn't just a good idea. 00:05:04.579 --> 00:05:08.319 It's a core daily nursing responsibility and, 00:05:08.319 --> 00:05:10.899 you know, a massive exam topic. OK, so let's 00:05:10.899 --> 00:05:13.810 shift to manifestations. For a younger, healthy 00:05:13.810 --> 00:05:16.250 adult, the symptoms are pretty classic, right? 00:05:16.709 --> 00:05:20.029 The lower urinary tract symptoms, or LUTs. Correct. 00:05:20.509 --> 00:05:23.170 You're looking for dysuria, that burning, painful 00:05:23.170 --> 00:05:25.970 feeling during urination. Then you have urinary 00:05:25.970 --> 00:05:28.069 frequency, which is often defined as needing 00:05:28.069 --> 00:05:30.529 to go more than every two hours. Urgency too. 00:05:30.769 --> 00:05:33.810 Urgency, and sometimes a little suprapubic discomfort 00:05:33.810 --> 00:05:36.089 or pressure. These are really the classic signs 00:05:36.089 --> 00:05:38.910 of cystitis. But, and this is the big but, the 00:05:38.910 --> 00:05:40.829 clinical priority cue, the thing that I think 00:05:40.829 --> 00:05:43.300 really throws people off is the presentation 00:05:43.300 --> 00:05:46.980 in the elderly. This is 100 % high -yield information 00:05:46.980 --> 00:05:49.980 right here. In an older adult, their whole inflammatory 00:05:49.980 --> 00:05:51.720 response can be blunted. They might not mount 00:05:51.720 --> 00:05:53.779 a fever. They might not even complain about pain 00:05:53.779 --> 00:05:55.660 when they urinate. So what do you see instead? 00:05:56.019 --> 00:05:59.019 Instead, the absolute critical finding is often 00:05:59.019 --> 00:06:02.199 a sudden, totally unexplained change in cognitive 00:06:02.199 --> 00:06:06.199 function. New onset confusion, delirium, or even 00:06:06.199 --> 00:06:09.379 just generalized malaise and fatigue. Sometimes 00:06:09.379 --> 00:06:12.180 those are the only signs of a severe UTI, or 00:06:12.180 --> 00:06:14.339 even the beginning of urosepsis. So take home 00:06:14.339 --> 00:06:16.959 is, if you have an older patient with new confusion, 00:06:17.579 --> 00:06:19.420 UTI has to be at the top of your differential. 00:06:19.740 --> 00:06:22.139 Immediately, you have to rule it out. Let's talk 00:06:22.139 --> 00:06:25.120 about meds for these uncomplicated UTIs. It's 00:06:25.120 --> 00:06:27.439 usually a short course of antibiotics. What are 00:06:27.439 --> 00:06:29.319 the common ones and what are the critical teaching 00:06:29.319 --> 00:06:31.540 points for us? Okay, so the standard short course 00:06:31.540 --> 00:06:34.319 is often trimethoprims sulfamethoxazole, which 00:06:34.319 --> 00:06:37.360 is TMP SMX, nitroferantoin, or phosphomycin. 00:06:37.939 --> 00:06:40.339 But let's really focus on the two big drug alerts 00:06:40.339 --> 00:06:42.439 that the sources highlight. Give us the first 00:06:42.439 --> 00:06:45.920 one, the absolute must -know detail for nitroferantoin. 00:06:46.560 --> 00:06:48.759 Nitroferantoin is a fantastic drug for lower 00:06:48.759 --> 00:06:51.920 UTIs, but its use completely hinders on the patient's 00:06:51.920 --> 00:06:54.920 renal function. The key nursing consideration 00:06:54.920 --> 00:06:57.459 is you must check the patient's creatinine clearance, 00:06:57.800 --> 00:07:00.620 the CRCL. And what's the cutoff? If the CRCL 00:07:00.620 --> 00:07:03.300 is less than 30 milliliters per minute, the drug 00:07:03.300 --> 00:07:06.300 is contraindicated. And why is that? It's twofold. 00:07:06.600 --> 00:07:09.680 When renal function is that poor, the drug doesn't 00:07:09.680 --> 00:07:12.019 concentrate in the urine enough to actually kill 00:07:12.019 --> 00:07:15.060 the bacteria, so it's ineffective. But worse, 00:07:15.459 --> 00:07:17.839 it accumulates in the rest of the body systemically, 00:07:18.139 --> 00:07:20.139 and that increases the risk of some really serious 00:07:20.139 --> 00:07:22.519 side effects, like peripheral neuropathy. So 00:07:22.519 --> 00:07:25.379 that lab value is a hard stop. It's an absolute 00:07:25.379 --> 00:07:27.860 clinical barrier. You have to check it. OK, that's 00:07:27.860 --> 00:07:31.399 the definite need to know. Now, for symptom relief, 00:07:31.819 --> 00:07:34.740 because these patients are miserable. Phenazapyridine 00:07:34.740 --> 00:07:37.639 or pyridium is often used. What's the mandatory 00:07:37.639 --> 00:07:39.699 patient education for that one? The teaching 00:07:39.699 --> 00:07:42.980 for phenazoperidine is so critical for, you know, 00:07:43.040 --> 00:07:45.040 just preventing patient panic. It's a topical 00:07:45.040 --> 00:07:47.819 analgesic. It basically coats the inside of the 00:07:47.819 --> 00:07:50.259 urinary tract to reduce that burning and urgency. 00:07:50.439 --> 00:07:52.000 And you have to warn them. You must warn them 00:07:52.000 --> 00:07:54.560 that it causes a really dramatic but totally 00:07:54.560 --> 00:07:57.540 harmless change in their urine color. We're talking 00:07:57.540 --> 00:08:00.959 bright orange, sometimes a reddish brown. And 00:08:00.959 --> 00:08:04.339 it will stain everything. Clothing, contact lenses, 00:08:04.660 --> 00:08:06.800 the toilet bowl. If you forget to tell them that, 00:08:06.819 --> 00:08:07.959 they're going to think they're bleeding to death 00:08:07.959 --> 00:08:09.920 and they'll be right back in the ER. Excellent 00:08:09.920 --> 00:08:12.600 point. OK, now let's get to the core nursing 00:08:12.600 --> 00:08:16.779 implications. Beyond giving meds, how do we intervene 00:08:16.779 --> 00:08:18.839 to manage this and prevent it from coming back? 00:08:18.980 --> 00:08:21.480 Our management really comes down to three things, 00:08:21.959 --> 00:08:25.000 hydration, hygiene, and adherence. OK, break 00:08:25.000 --> 00:08:27.160 that down. So for a SES monitor, we're getting 00:08:27.160 --> 00:08:29.839 a baseline mental status, especially in our older 00:08:29.839 --> 00:08:33.120 adults, checking their pain level and monitoring 00:08:33.120 --> 00:08:35.500 their hydration status with I's and O's. And 00:08:35.500 --> 00:08:38.509 for intervene? We push fluids. aggressively. 00:08:38.970 --> 00:08:41.649 The goal is at least eight large glasses of water 00:08:41.649 --> 00:08:43.809 a day, or about two and a half liters. You want 00:08:43.809 --> 00:08:46.669 to keep that system constantly flushing. We also 00:08:46.669 --> 00:08:49.470 stress meticulous hygiene wiping front to back, 00:08:49.669 --> 00:08:51.490 voiding after intercourse, and just teaching 00:08:51.490 --> 00:08:53.350 them to empty their bladder completely every 00:08:53.350 --> 00:08:56.090 single time. And then educate is the adherence 00:08:56.090 --> 00:08:59.250 piece. Yes. We have to emphasize completing the 00:08:59.250 --> 00:09:01.429 entire course of antibiotics, even if they feel 00:09:01.429 --> 00:09:03.870 better in a day or two. If they stop early, it 00:09:03.870 --> 00:09:06.730 can lead to resistance and relapse. We also advise 00:09:06.730 --> 00:09:09.870 them to avoid bladder irritants, caffeine, alcohol, 00:09:10.169 --> 00:09:13.090 carbonated drinks during that acute phase. Perfect. 00:09:13.350 --> 00:09:15.169 So let's wrap this section with the highest yield 00:09:15.169 --> 00:09:17.889 points for the exam. Okay. Quick review summary 00:09:17.889 --> 00:09:20.809 for UTI. Priority assessment in the elderly. 00:09:21.710 --> 00:09:25.429 New onset confusion or delirium. That mental 00:09:25.429 --> 00:09:28.809 status change is key. Fluid intake goal. Minimum 00:09:28.809 --> 00:09:32.049 eight glasses or 2 .5 liters a day. Flush the 00:09:32.049 --> 00:09:34.690 system. Nitrofurenzoid alert. Contra indicated 00:09:34.690 --> 00:09:37.230 if CRCL is less than 30, you have to check that 00:09:37.230 --> 00:09:40.269 lab. And Fidesoperidine? Harmless but very intense 00:09:40.269 --> 00:09:42.110 red or orange urine. Don't forget to teach that. 00:09:42.250 --> 00:09:45.649 And finally, CIUTI prevention. Strict aseptic 00:09:45.649 --> 00:09:47.590 technique on insertion, but more importantly, 00:09:47.830 --> 00:09:49.970 as the nurse, you have to advocate for prompt 00:09:49.970 --> 00:09:52.389 catheter removal. Get it out as soon as it's 00:09:52.389 --> 00:09:54.629 no longer medically necessary. Now let's make 00:09:54.629 --> 00:09:57.070 the jump from that lower tract infection, cystitis, 00:09:57.509 --> 00:10:00.830 to an upper tract infection. Right. Acute pylonephritis. 00:10:01.210 --> 00:10:03.169 And this is a total game changer, right? This 00:10:03.169 --> 00:10:06.370 takes the infection from being a localized annoyance 00:10:06.370 --> 00:10:09.429 to a systemic life -threatening crisis. It's 00:10:09.429 --> 00:10:12.389 a huge leap. With pylonephritis, those ascending 00:10:12.389 --> 00:10:16.049 bacteria, again, often E. coli, Proteus, or Klebsiella, 00:10:16.330 --> 00:10:18.169 they've made it all the way up to the renal parenchyma 00:10:18.169 --> 00:10:20.450 and the pelvis. They're inside the kidney itself. 00:10:20.700 --> 00:10:23.259 And that causes widespread inflammation, edema, 00:10:23.639 --> 00:10:25.700 even micro abscesses to form within the kidney 00:10:25.700 --> 00:10:28.279 tissue. So unlike a bladder infection that's 00:10:28.279 --> 00:10:31.379 kind of contained, this is a deep organ infection 00:10:31.379 --> 00:10:34.019 and it triggers a much, much stronger systemic 00:10:34.019 --> 00:10:36.240 inflammatory response. And if it's recurrent, 00:10:36.279 --> 00:10:39.019 it can cause long -term damage. Absolutely. That 00:10:39.019 --> 00:10:41.620 inflammation leads to scarring and over time 00:10:41.620 --> 00:10:44.159 that scarring can lead to chronic kidney disease. 00:10:44.340 --> 00:10:47.320 So because this is now a systemic disease, the 00:10:47.320 --> 00:10:49.279 manifestations are radically different from a 00:10:49.279 --> 00:10:52.200 simple UTI. What's the cardinal sign that tells 00:10:52.200 --> 00:10:55.379 you, this is pilonephritis, not cystitis? It's 00:10:55.379 --> 00:10:57.940 the combination of systemic symptoms and flank 00:10:57.940 --> 00:11:00.980 pain. These patients present with a really rapid 00:11:00.980 --> 00:11:04.039 onset of high fever. We're talking 103 degrees 00:11:04.039 --> 00:11:06.799 or higher shaking chills, severe malaise, and 00:11:06.799 --> 00:11:08.700 often pretty significant nausea and vomiting. 00:11:08.840 --> 00:11:11.139 And the flank pain is key? It is the key local 00:11:11.139 --> 00:11:13.899 sign. It's pain in the costovertable angle or 00:11:13.899 --> 00:11:17.200 CVA tenderness. That flank pain means the infection 00:11:17.200 --> 00:11:19.580 is literally stretching the capsule of the kidney. 00:11:19.690 --> 00:11:22.330 Can you just briefly describe that CVA assessment? 00:11:22.629 --> 00:11:24.629 I feel like that's a key physical finding we 00:11:24.629 --> 00:11:28.529 have to know. For sure. CVA tenderness is assessed 00:11:28.529 --> 00:11:31.769 by either palpation or light percussion. Sometimes 00:11:31.769 --> 00:11:34.289 it's called a renal punch or a thumb break at 00:11:34.289 --> 00:11:36.690 that angle formed by the 12th rib and the spine. 00:11:36.750 --> 00:11:39.309 And if it's positive? If that light tap elicits 00:11:39.309 --> 00:11:42.370 sharp, intense pain, it's a very strong indicator 00:11:42.370 --> 00:11:44.750 of kidney involvement, either from infection 00:11:44.750 --> 00:11:47.429 or an obstruction. That pain, plus the high fever 00:11:47.429 --> 00:11:50.250 and chills, That paints a really critical picture. 00:11:50.409 --> 00:11:52.210 And this level of infection immediately brings 00:11:52.210 --> 00:11:56.409 up our third major priority. Sepsis risk. How 00:11:56.409 --> 00:11:58.730 fast can this progress to UroSepsis and what 00:11:58.730 --> 00:12:01.409 are the signs of impending septic shock? UroSepsis 00:12:01.409 --> 00:12:03.450 is a massive, massive threat. The kidneys are 00:12:03.450 --> 00:12:05.350 incredibly vascular organs, so it's very easy 00:12:05.350 --> 00:12:07.129 for those bacteria to get into the bloodstream. 00:12:07.389 --> 00:12:10.090 That's Bactremia. OK. The signs of septic shock 00:12:10.090 --> 00:12:12.809 would be a rapid onset of hemodynamic instability, 00:12:13.029 --> 00:12:15.149 so persistent low blood pressure or hypotension, 00:12:15.210 --> 00:12:17.730 even after you give them IV fluids, an increased 00:12:17.730 --> 00:12:21.330 heart rate, tachycardia, rapid breathing, and 00:12:21.330 --> 00:12:23.509 critical labs like an elevated lactate level. 00:12:23.659 --> 00:12:25.919 Recognizing the initial high fever and chills 00:12:25.919 --> 00:12:28.519 as the first warning sign of sepsis is just paramount. 00:12:28.740 --> 00:12:31.299 It requires immediate escalation. So given that 00:12:31.299 --> 00:12:33.860 sepsis risk, the interprofessional management 00:12:33.860 --> 00:12:37.039 has to be aggressive and usually hospital -based. 00:12:37.500 --> 00:12:40.360 What does that initial antibiotic and fluid strategy 00:12:40.360 --> 00:12:43.820 look like? Yeah, for severe cases, hospitalization 00:12:43.820 --> 00:12:46.159 is definitely necessary. You're starting with 00:12:46.159 --> 00:12:49.039 IV fluid replacement immediately. They're often 00:12:49.039 --> 00:12:51.639 dehydrated from the vomiting and the fever. And 00:12:51.639 --> 00:12:55.659 then you start empirical broad spectrum. IV antibiotics 00:12:55.659 --> 00:12:57.919 before the cultures come back. Absolutely. You 00:12:57.919 --> 00:13:00.480 can't wait. You're typically using a fluoroquinolone 00:13:00.480 --> 00:13:04.080 like Cipro or maybe an extended spectrum cephalosporin. 00:13:04.080 --> 00:13:06.799 You have to start targeting the most likely culprits, 00:13:06.899 --> 00:13:09.379 those gram negative bacteria right away. And 00:13:09.379 --> 00:13:11.700 once the patient starts to stabilize, I assume 00:13:11.700 --> 00:13:14.340 the antibiotic course changes. It does. Once 00:13:14.340 --> 00:13:16.500 they're a febrile and clinically improving, you 00:13:16.500 --> 00:13:19.379 can transition them from IV to oral antibiotics. 00:13:19.799 --> 00:13:22.860 But and this is a huge point, this is not a short 00:13:22.860 --> 00:13:25.860 course like for a UTI. Pyelonephritis requires 00:13:25.860 --> 00:13:29.000 a minimum of 14 days and often up to 21 days 00:13:29.000 --> 00:13:31.059 of oral therapy. And that's to make sure you've 00:13:31.059 --> 00:13:33.120 completely cleared the infection from the kidney 00:13:33.120 --> 00:13:35.639 tissue itself. Exactly, to prevent abscesses 00:13:35.639 --> 00:13:38.039 or a chronic recurrence. Okay, so for the nurse 00:13:38.039 --> 00:13:40.480 managing this patient, monitoring for septic 00:13:40.480 --> 00:13:43.100 shock is obviously number one. What else is essential 00:13:43.100 --> 00:13:46.690 on, say, a four -hour assessment schedule? Okay, 00:13:46.690 --> 00:13:49.409 so for a SES monitor, we're doing frequent temperature 00:13:49.409 --> 00:13:51.870 and vital signs, always looking for that drop 00:13:51.870 --> 00:13:54.769 in BP or spike in heart rate or respiratory rate. 00:13:55.250 --> 00:13:57.909 We're monitoring their pain, specifically that 00:13:57.909 --> 00:14:02.710 CVA tenderness. Strict I and O is crucial both 00:14:02.710 --> 00:14:05.710 to track urine output for perfusion and to track 00:14:05.710 --> 00:14:08.009 their fluid status with all the IV fluids we're 00:14:08.009 --> 00:14:10.470 given. And interventions. Intervene is all about 00:14:10.470 --> 00:14:12.830 prompt administration of those IV fluids and 00:14:12.830 --> 00:14:15.210 antibiotics. That's a time -sensitive, life -saving 00:14:15.210 --> 00:14:18.049 intervention. We're also giving aggressive pain 00:14:18.049 --> 00:14:20.870 control with analgesics and using antipyretics 00:14:20.870 --> 00:14:22.970 to bring that fever down and reduce the metabolic 00:14:22.970 --> 00:14:25.730 demand. And what about patient education? Education 00:14:25.730 --> 00:14:28.509 focuses on the risk of relapse. They have to 00:14:28.509 --> 00:14:30.509 understand why they need to complete that long 00:14:30.509 --> 00:14:32.690 course of antibiotics. And they also need to 00:14:32.690 --> 00:14:34.149 know they'll need a follow -up urine culture 00:14:34.149 --> 00:14:36.450 after treatment to make sure the urine is sterile. 00:14:36.690 --> 00:14:39.490 Let's do a quick review summary for acute pilonephritis. 00:14:39.950 --> 00:14:43.700 Okay. Defining sign. CVA tenderness or flank 00:14:43.700 --> 00:14:46.340 pain combined with a high systemic fever, chills, 00:14:46.899 --> 00:14:49.549 and usually nausea and vomiting. management priority. 00:14:49.870 --> 00:14:52.029 Immediate fall dehydration and prompt empirical 00:14:52.029 --> 00:14:54.850 broad -spectrum antibiotics to prevent uricepsis. 00:14:55.009 --> 00:14:56.909 And the long -term risk. Recurrent infections 00:14:56.909 --> 00:14:59.590 can lead to chronic scarring and eventually potential 00:14:59.590 --> 00:15:02.289 end -stage renal disease. Okay, we are shifting 00:15:02.289 --> 00:15:04.409 gears completely now. We're moving away from 00:15:04.409 --> 00:15:06.629 bacterial invasion and into conditions where 00:15:06.629 --> 00:15:09.330 the body is basically attacking itself. We're 00:15:09.330 --> 00:15:11.470 looking at diseases where the glomerulus, the 00:15:11.470 --> 00:15:15.190 kidney's tiny delicate filtration unit, is damaged 00:15:15.190 --> 00:15:18.539 by an immune response. And this leads us directly 00:15:18.539 --> 00:15:22.700 to our first major priority, massive fluid balance 00:15:22.700 --> 00:15:25.399 shifts. Let's start with acute post -striptococcal 00:15:25.399 --> 00:15:29.159 glomerulonephritis, or APSGN. The pathophysiology 00:15:29.159 --> 00:15:31.940 of APSGN is really a classic example of what's 00:15:31.940 --> 00:15:34.480 called a type 3 hypersensitivity. It's caused 00:15:34.480 --> 00:15:37.139 by circulating antigen antibody complexes. Okay, 00:15:37.200 --> 00:15:39.279 what does that mean in simple terms? It means 00:15:39.279 --> 00:15:42.139 that after an infection, usually a group A beta 00:15:42.139 --> 00:15:44.240 hemolytic strep infection like strep throat or 00:15:44.240 --> 00:15:46.940 even a skin infection like impetigo, the body 00:15:46.940 --> 00:15:49.379 creates these little immune complexes. And the 00:15:49.379 --> 00:15:52.240 critical point is the timing. The kidney damage 00:15:52.240 --> 00:15:55.519 happens five to 21 days after the initial infection 00:15:55.519 --> 00:15:58.179 is already gone. So the body's own defense system 00:15:58.179 --> 00:16:01.240 is causing the problem. Exactly. These complexes 00:16:01.240 --> 00:16:03.659 get lodged in the glomerular basement membrane. 00:16:03.740 --> 00:16:06.480 They trigger this big inflammatory reaction and 00:16:06.480 --> 00:16:08.940 that severely reduces the glomerular filtration 00:16:08.940 --> 00:16:12.120 rate or GFR. And when that filtration rate drops, 00:16:12.679 --> 00:16:16.080 the kidney can't clear waste and more importantly, 00:16:16.220 --> 00:16:18.919 it can't manage fluid. So what does that reduced 00:16:18.919 --> 00:16:22.340 GFR look like clinically? It creates the classic 00:16:22.340 --> 00:16:25.759 APSGN triad. fluid overload, hypertension, and 00:16:25.759 --> 00:16:28.059 visible changes in the urine. The fluid overload 00:16:28.059 --> 00:16:31.059 usually appears first as generalized edema. It 00:16:31.059 --> 00:16:33.500 often starts with this really striking periorbital 00:16:33.500 --> 00:16:35.320 edema, especially when they wake up in the morning. 00:16:35.379 --> 00:16:38.840 Puffy eyes. Very puffy eyes. And then that progresses 00:16:38.840 --> 00:16:42.559 to peripheral edema. Because the GFR is so low, 00:16:42.720 --> 00:16:45.419 the body holds onto sodium and water, which leads 00:16:45.419 --> 00:16:48.559 to a big rise in plasma volume and, as a result, 00:16:49.000 --> 00:16:51.279 pretty severe hypertension. And the urine changes. 00:16:51.820 --> 00:16:53.899 They must tell a clear story about the filter 00:16:53.899 --> 00:16:56.740 being damaged. They do. First you see oliguria, 00:16:57.000 --> 00:17:00.059 which is just reduced urine output. But the characteristic 00:17:00.059 --> 00:17:02.860 sign is hematuria, where red blood cells are 00:17:02.860 --> 00:17:05.259 leaking through those damaged glomeruli. The 00:17:05.259 --> 00:17:08.140 urine is often described as looking smoky. T 00:17:08.140 --> 00:17:10.539 -colored or rusty. And you see protein, too. 00:17:10.619 --> 00:17:14.000 Yes, moderate proteinuria as well. And diagnostics, 00:17:14.000 --> 00:17:17.119 particularly an ASO titer, can help confirm that 00:17:17.119 --> 00:17:20.180 preceding strep infection. So the goals for interprofessional 00:17:20.180 --> 00:17:21.839 management are really just supportive, right? 00:17:21.839 --> 00:17:24.460 You're focused on controlling those two big complications, 00:17:24.920 --> 00:17:27.920 the hypertension and the volume overload. That's 00:17:27.920 --> 00:17:30.680 100 % correct. We're treating the symptoms while 00:17:30.680 --> 00:17:33.440 the immune system recovers. Rest is actually 00:17:33.440 --> 00:17:36.059 essential until the hypertension and hematuria 00:17:36.059 --> 00:17:39.400 start to subside. And pharmacologically, we use 00:17:39.400 --> 00:17:42.160 aggressive antihypertensives and, critically, 00:17:42.519 --> 00:17:45.099 diuretics to pull off all that excess fluid. 00:17:45.660 --> 00:17:47.980 Antibiotics are only used if, for some reason, 00:17:48.140 --> 00:17:50.059 the original strep infection is still active, 00:17:50.140 --> 00:17:53.099 which is pretty rare. So given the danger of 00:17:53.099 --> 00:17:55.779 that uncontrolled hypertension, The nursing role 00:17:55.779 --> 00:17:58.839 in monitoring fluid and pressure has to be meticulous. 00:17:59.319 --> 00:18:02.420 What are the key measurements? OK, so for a SES 00:18:02.420 --> 00:18:04.640 monitor, blood pressure has to be checked frequently, 00:18:04.819 --> 00:18:07.559 often every two to four hours. Any significant 00:18:07.559 --> 00:18:10.140 elevation needs to be reported immediately. But 00:18:10.140 --> 00:18:12.559 the gold standard for tracking fluid status is 00:18:12.559 --> 00:18:15.099 daily weights. Same time, same scale. Same time 00:18:15.099 --> 00:18:17.259 every morning, same scale before they eat. It's 00:18:17.259 --> 00:18:19.819 the most accurate indicator. And of course, strict 00:18:19.819 --> 00:18:23.279 INO is mandatory. We also watch their BUN and 00:18:23.279 --> 00:18:25.680 creatinine to track how well the filtration is 00:18:25.680 --> 00:18:27.660 recovering. And intervention. For intervene, 00:18:28.259 --> 00:18:30.440 strict adherence to sodium and fluid restrictions 00:18:30.440 --> 00:18:33.240 is critical if they have that hypertension and 00:18:33.240 --> 00:18:36.000 edema. The fluid restriction is often calculated 00:18:36.000 --> 00:18:38.640 based on the previous day's urine output, plus 00:18:38.640 --> 00:18:41.000 a little extra for insensible losses. What about 00:18:41.000 --> 00:18:43.200 protein? Protein restriction is reserved only 00:18:43.200 --> 00:18:45.579 for patients who are showing signs of severe 00:18:45.579 --> 00:18:48.299 uremia, like a really high BUN. Otherwise it's 00:18:48.299 --> 00:18:51.359 not restricted. And for education. is all about 00:18:51.359 --> 00:18:53.539 adherence to that diet and fluid restriction 00:18:53.539 --> 00:18:55.940 and really the importance of preventing future 00:18:55.940 --> 00:18:58.500 strep infections by seeking prompt treatment 00:18:58.500 --> 00:19:00.920 for sore throats or skin infections. Let's do 00:19:00.920 --> 00:19:04.740 the quick review for APSGM. The classic triad, 00:19:05.079 --> 00:19:08.400 edema, which is initially periobital, hypertension, 00:19:08.599 --> 00:19:11.579 and hematuria, that smoky, tea -colored urine. 00:19:11.660 --> 00:19:14.019 And the timing. It occurs one to three weeks 00:19:14.019 --> 00:19:16.539 after a group A strep infection. And the number 00:19:16.539 --> 00:19:19.180 one nursing priority. Aggressive monitoring and 00:19:19.180 --> 00:19:22.059 control of blood pressure and fluid status. So 00:19:22.059 --> 00:19:25.000 that means strict daily weights in I's and O's. 00:19:25.299 --> 00:19:27.599 OK, now let's look into Frodeck syndrome. If 00:19:27.599 --> 00:19:30.599 APSGN is about the filter getting clogged and 00:19:30.599 --> 00:19:33.140 reducing GFR, Frodeck syndrome sounds like the 00:19:33.140 --> 00:19:36.359 filter just becomes Leaky. That's a perfect way 00:19:36.359 --> 00:19:39.859 to put it. The core pathophysiology here is a 00:19:39.859 --> 00:19:42.299 massive increase in glomerular permeability. 00:19:42.859 --> 00:19:45.559 It allows large molecules, specifically plasma 00:19:45.559 --> 00:19:48.799 proteins, to just pour out into the urine. And 00:19:48.799 --> 00:19:51.519 that's the definition of it, right? Massive proteinuria. 00:19:51.660 --> 00:19:54.180 Exactly. Typically greater than three and a half 00:19:54.180 --> 00:19:56.460 grams of protein loss per day. And this leads 00:19:56.460 --> 00:20:00.440 to severe hypoalbuminemia, very low levels of 00:20:00.440 --> 00:20:02.920 albumin circulating in the blood. And that profound 00:20:02.920 --> 00:20:05.240 drop in albumin is what triggers the life changing 00:20:05.240 --> 00:20:08.039 manifestation of this disease. It is. Albumin 00:20:08.039 --> 00:20:10.019 is what's responsible for maintaining oncotic 00:20:10.019 --> 00:20:12.380 pressure, which is what keeps fluid inside your 00:20:12.380 --> 00:20:14.619 blood vessels. When all that albumin leaks out, 00:20:14.720 --> 00:20:16.839 the oncotic pressure just plummets. And fluid 00:20:16.839 --> 00:20:19.170 shifts out. aggressively. It shifts out of the 00:20:19.170 --> 00:20:21.150 vascular space and into the interstitial space. 00:20:21.390 --> 00:20:23.509 And the result is the hallmark sign of nephotic 00:20:23.509 --> 00:20:27.549 syndrome. Severe generalized pitting edema. We 00:20:27.549 --> 00:20:29.650 call it anisarca. It can be so severe, it actually 00:20:29.650 --> 00:20:32.210 impairs mobility and breathing. And beyond the 00:20:32.210 --> 00:20:34.970 edema, the body tries to compensate for this 00:20:34.970 --> 00:20:37.369 protein loss, which leads to a secondary problem 00:20:37.369 --> 00:20:40.630 we have to watch for. Yes, hyperlipidemia. The 00:20:40.630 --> 00:20:43.089 liver senses this massive protein loss and it 00:20:43.089 --> 00:20:45.670 tries to compensate by ramping up protein synthesis. 00:20:46.049 --> 00:20:48.210 But unfortunately, it also ramps up the production 00:20:48.210 --> 00:20:51.970 of lipoproteins, and that results in severe hyperlipidemia 00:20:51.970 --> 00:20:54.329 and high cholesterol, which puts them at long 00:20:54.329 --> 00:20:57.609 -term cardiovascular risk. critical associated 00:20:57.609 --> 00:21:01.269 risks. One is susceptibility to infection. What's 00:21:01.269 --> 00:21:03.569 the other less obvious, but really dangerous 00:21:03.569 --> 00:21:06.529 one? The hidden danger, and this is a major testable 00:21:06.529 --> 00:21:09.630 concept, is hypercoagulability. The blood clotting? 00:21:09.730 --> 00:21:12.589 Yes. The massive protein loss doesn't just include 00:21:12.589 --> 00:21:15.390 albumin. The patient is also losing their natural 00:21:15.390 --> 00:21:18.130 anticoagulant proteins, specifically antithrombin 00:21:18.130 --> 00:21:22.269 3, into the urine. This creates a severe prothrombotic 00:21:22.269 --> 00:21:25.150 state. It puts them at a very high risk for DVTs, 00:21:25.329 --> 00:21:27.690 pulmonary embol - and even renal vein thrombosis. 00:21:27.750 --> 00:21:30.230 Wow. So given all that complexity, the management 00:21:30.230 --> 00:21:32.029 involves a few different medication classes. 00:21:32.089 --> 00:21:34.009 What are the main ones? The primary treatment 00:21:34.009 --> 00:21:36.430 is to address the underlying inflammation, often 00:21:36.430 --> 00:21:38.730 with corticosteroids like high -dose pritansone. 00:21:39.210 --> 00:21:41.869 To manage the protein loss itself, we often use 00:21:41.869 --> 00:21:45.250 ACE inhibitors or ARBs. How do those help with 00:21:45.250 --> 00:21:47.529 protein loss? They actually reduce the filtration 00:21:47.529 --> 00:21:50.210 pressure inside the glomerulus, which physically 00:21:50.210 --> 00:21:52.329 reduces the amount of protein that can leak out. 00:21:52.710 --> 00:21:55.069 And of course, we use diuretics to manage the 00:21:55.069 --> 00:21:58.579 extr... and anti -hyperlipidemics for the high 00:21:58.579 --> 00:22:00.619 cholesterol. And interprofessional management 00:22:00.619 --> 00:22:02.920 has to include a dietitian here. What are the 00:22:02.920 --> 00:22:05.539 nutritional considerations? A dietitian consult 00:22:05.539 --> 00:22:08.119 is absolutely essential. The patient might need 00:22:08.119 --> 00:22:10.579 a moderate protein intake to try and balance 00:22:10.579 --> 00:22:13.079 a loss without overburdening the kidneys, but 00:22:13.079 --> 00:22:16.319 the primary dietary focus is a strict low -sodium 00:22:16.319 --> 00:22:19.140 diet to help manage all that edema and fluid 00:22:19.140 --> 00:22:21.980 retention. So shifting to nursing management, 00:22:22.359 --> 00:22:25.150 if a patient has Anisarca, their skin must be 00:22:25.150 --> 00:22:28.069 incredibly vulnerable. What's our priority? Meticulous 00:22:28.069 --> 00:22:30.609 skincare and integrity is paramount. The skin 00:22:30.609 --> 00:22:32.950 over those edematous areas is stretched, it's 00:22:32.950 --> 00:22:35.990 fragile, and it's so prone to breakdown and then 00:22:35.990 --> 00:22:37.549 subsequent infection. So what does that look 00:22:37.549 --> 00:22:40.509 like in practice? OK, so for a SES monitor, we 00:22:40.509 --> 00:22:43.130 are checking their edema, looking for pitting, 00:22:43.430 --> 00:22:46.170 measuring abdominal girth. We're constantly monitoring 00:22:46.170 --> 00:22:48.769 their skin integrity. And we're always watching 00:22:48.769 --> 00:22:52.049 for signs of infection or thrombosis. And interventions. 00:22:52.430 --> 00:22:55.309 For intervene, it's frequent repositioning, gentle 00:22:55.309 --> 00:22:58.460 handling. using pressure redistribution surfaces, 00:22:59.059 --> 00:23:02.000 elevating edematous limbs. And because they often 00:23:02.000 --> 00:23:04.660 have a poor appetite from all these sites, we 00:23:04.660 --> 00:23:07.440 offer small, frequent, appealing meals to get 00:23:07.440 --> 00:23:10.640 their calories in. And, you know, just providing 00:23:10.640 --> 00:23:12.839 emotional support for the massive changes in 00:23:12.839 --> 00:23:15.259 their body image. And education. We teach them 00:23:15.259 --> 00:23:17.619 to monitor their weight daily and report any 00:23:17.619 --> 00:23:20.380 signs of infection or swelling immediately. And 00:23:20.380 --> 00:23:22.299 we really have to emphasize the importance of 00:23:22.299 --> 00:23:24.880 that low sodium diet and sticking to their steroid 00:23:24.880 --> 00:23:26.839 regimen. Let's do a quick review summary for 00:23:26.839 --> 00:23:30.799 nephrotic syndrome. Okay. Defining feature. Massive 00:23:30.799 --> 00:23:32.640 proteinuria, more than three and a half grams 00:23:32.640 --> 00:23:35.259 a day leading to severe generalized edema or 00:23:35.259 --> 00:23:38.559 anisarca and hypoalbuminemia. The hidden danger. 00:23:38.819 --> 00:23:40.920 High risk of hypercoagulability because they're 00:23:40.920 --> 00:23:43.319 losing anti -chrompin 3. And the nursing priority. 00:23:43.880 --> 00:23:46.819 Meticulous skin care and vigilant infection prevention. 00:23:47.200 --> 00:23:50.579 And the management is corticosteroids and ACE 00:23:50.579 --> 00:23:54.039 inhibitors with a low sodium, moderate protein 00:23:54.039 --> 00:23:57.619 diet. We have now reached our second major priority. 00:23:59.079 --> 00:24:01.859 Acute, severe pain. And I don't think you can 00:24:01.859 --> 00:24:03.180 talk about that without talking about kidney 00:24:03.180 --> 00:24:05.299 stones. I mean, it's one of the most painful 00:24:05.299 --> 00:24:07.660 conditions a person can experience. It really 00:24:07.660 --> 00:24:09.680 is. So let's talk about the pathophysiology. 00:24:10.170 --> 00:24:12.329 Why do these crystals even form in the first 00:24:12.329 --> 00:24:14.829 place? It all revolves around something called 00:24:14.829 --> 00:24:17.369 supersaturation. It's when the concentration 00:24:17.369 --> 00:24:19.650 of certain salts in the urine gets so high that 00:24:19.650 --> 00:24:22.049 they can't stay dissolved anymore. So they start 00:24:22.049 --> 00:24:24.329 to precipitate out and form crystals that clump 00:24:24.329 --> 00:24:26.410 together. And what causes that supersaturation? 00:24:26.509 --> 00:24:29.609 It's complex. It can be low urine volume from 00:24:29.609 --> 00:24:32.690 dehydration, genetics, diet, metabolic diseases. 00:24:33.269 --> 00:24:36.130 It's really multifactorial. The source outlined 00:24:36.130 --> 00:24:39.109 four major types of stones. And knowing the type 00:24:39.109 --> 00:24:41.509 is key for prevention. It's everything for prevention. 00:24:41.769 --> 00:24:43.730 So number one is calcium oxalate. That's the 00:24:43.730 --> 00:24:46.730 most common. About 70 % to 80 % of stones. Number 00:24:46.730 --> 00:24:49.990 two is uric acid. About 5 % to 10%. These are 00:24:49.990 --> 00:24:53.170 associated with gout and high purine diets. Things 00:24:53.170 --> 00:24:56.569 like red meat and alcohol. Exactly. Number three 00:24:56.569 --> 00:25:00.369 is streuvite. About 10 % to 15%. And this is 00:25:00.369 --> 00:25:03.349 the infection stone. Why is it called that? because 00:25:03.349 --> 00:25:06.250 these are almost always caused by UTIs with certain 00:25:06.250 --> 00:25:09.349 kinds of bacteria, mainly proteus. The bacteria 00:25:09.349 --> 00:25:12.910 raise the UNPH, which allows these big, complex 00:25:12.910 --> 00:25:15.529 staghorn stones to form that can fill the entire 00:25:15.529 --> 00:25:18.410 renal pelvis. And the last one is rare. Yeah, 00:25:18.569 --> 00:25:20.069 cysteine stones are rare. They are from a genetic 00:25:20.069 --> 00:25:22.450 defect in amino acid metabolism. So let's talk 00:25:22.450 --> 00:25:25.390 about the pain itself, renal colic. What causes 00:25:25.390 --> 00:25:28.339 that sheer intensity? Well, the pain isn't actually 00:25:28.339 --> 00:25:30.339 caused by the stone just sitting there. It's 00:25:30.339 --> 00:25:32.500 caused by the obstruction when the stone tries 00:25:32.500 --> 00:25:36.019 to pass. As the stone moves, it blocks the ureter 00:25:36.019 --> 00:25:39.339 and urine backs up behind it. That's called hydronephrosis. 00:25:39.740 --> 00:25:42.279 And that fluid retention stretches the sensitive 00:25:42.279 --> 00:25:44.740 walls of the ureter and the kibbe capsule, causing 00:25:44.740 --> 00:25:47.779 these intense agonizing spasms. That's why the 00:25:47.779 --> 00:25:50.960 pain is so sudden and excruciating. And the location 00:25:50.960 --> 00:25:52.900 of the pain can actually help you track where 00:25:52.900 --> 00:25:55.559 the stone is. It can. Pain that's high up in 00:25:55.559 --> 00:25:57.500 the flank suggests the stone is still in the 00:25:57.500 --> 00:26:00.880 kidney or the upper part of the ureter. As the 00:26:00.880 --> 00:26:03.119 stone moves down, the pain typically radiates 00:26:03.119 --> 00:26:06.140 sharply down to the groin, the inner thigh, the 00:26:06.140 --> 00:26:09.339 labia, or the testes. And nausea and vomiting 00:26:09.339 --> 00:26:11.920 are super common because of the severity of that 00:26:11.920 --> 00:26:14.160 pain reflex. We mentioned our third priority, 00:26:14.480 --> 00:26:17.279 sepsis. What's the urologic emergency linked 00:26:17.279 --> 00:26:20.440 to kidney stones? The life -threatening emergency 00:26:20.440 --> 00:26:23.680 is an obstructed infected kidney. If a patient 00:26:23.680 --> 00:26:26.099 comes with renal colic and a fever and chills, 00:26:26.220 --> 00:26:28.900 that is a huge red flag. It means bacteria are 00:26:28.900 --> 00:26:31.700 trapped behind that stone. A closed system infection. 00:26:32.039 --> 00:26:34.700 Exactly. And that can escalate to Eurocepsis 00:26:34.700 --> 00:26:37.740 incredibly fast. It requires immediate urgent 00:26:37.740 --> 00:26:40.220 drainage with a stent or a nephrostomy tube before 00:26:40.220 --> 00:26:42.460 you even think about treating the stone. For 00:26:42.460 --> 00:26:44.619 acute management, our immediate priority is pain 00:26:44.619 --> 00:26:48.079 control. You mentioned earlier that NSAIDs are 00:26:48.079 --> 00:26:51.119 often preferred over opioids, which sounds counterintuitive 00:26:51.119 --> 00:26:53.829 for such intense pain. Why is that? It's a great 00:26:53.829 --> 00:26:57.289 question. And you often do need opioids for breakthrough 00:26:57.289 --> 00:27:01.750 pain. But NSAIDs, like Toradol, are often preferred 00:27:01.750 --> 00:27:04.250 because they treat two problems at once. They 00:27:04.250 --> 00:27:07.109 manage the pain, but they also reduce the inflammation 00:27:07.109 --> 00:27:09.890 and the swelling in the wall of the ureter. Which 00:27:09.890 --> 00:27:12.210 might help it pass. By reducing that swelling, 00:27:12.410 --> 00:27:14.650 they can potentially open up the ureter just 00:27:14.650 --> 00:27:17.549 enough to help facilitate spontaneous stone passage. 00:27:17.869 --> 00:27:20.529 And for bigger stones that won't pass? What are 00:27:20.529 --> 00:27:22.990 the common procedures? For stones bigger than 00:27:22.990 --> 00:27:25.329 about five millimeters, you'll need a procedure. 00:27:26.390 --> 00:27:30.069 Lithotripsy, or ESWL, uses non -invasive shock 00:27:30.069 --> 00:27:32.410 waves to break the stone up into smaller fragments 00:27:32.410 --> 00:27:35.769 that can be passed. For larger impacted stones, 00:27:35.990 --> 00:27:37.950 you might need a ureteroscopy to go up and grab 00:27:37.950 --> 00:27:40.430 it, or a percutaneous nephrolithotomy, which 00:27:40.430 --> 00:27:42.410 is a small surgical incision into the kidney 00:27:42.410 --> 00:27:45.329 to remove it directly. Okay, now to the critical 00:27:45.329 --> 00:27:47.869 nursing interventions. What is the single most 00:27:47.869 --> 00:27:50.210 important action a nurse must take for a patient 00:27:50.210 --> 00:27:52.769 with a suspected kidney stone? Strain all urine, 00:27:52.990 --> 00:27:55.730 every single drop. This is completely non -negotiable. 00:27:55.869 --> 00:27:57.809 And why is that so important? Because you have 00:27:57.809 --> 00:27:59.970 to capture that stone or its fragments and send 00:27:59.970 --> 00:28:02.470 it to the lab for analysis. Without knowing what 00:28:02.470 --> 00:28:05.410 the stone is made of, you can't create an effective 00:28:05.410 --> 00:28:08.109 long -term prevention plan, especially with diet. 00:28:08.289 --> 00:28:11.180 And beyond straining. What are our fluid goals 00:28:11.180 --> 00:28:13.759 once the acute crisis is over? Aggressive hydration. 00:28:14.259 --> 00:28:16.299 We're encouraging a really high fluid intake, 00:28:16.680 --> 00:28:18.680 often two to four liters a day, to get their 00:28:18.680 --> 00:28:21.359 urine output way up. This volume helps flush 00:28:21.359 --> 00:28:23.779 out any small fragments. Is there ever a time 00:28:23.779 --> 00:28:27.039 you wouldn't push fluids? Yes. If the patient 00:28:27.039 --> 00:28:30.099 has a complete... total obstruction and the kidney 00:28:30.099 --> 00:28:32.859 is backing up with hydronephrosis, you have to 00:28:32.859 --> 00:28:35.099 limit fluids until that obstruction is relieved 00:28:35.099 --> 00:28:37.339 to prevent further kidney damage. Let's talk 00:28:37.339 --> 00:28:39.759 about education, specifically after a procedure 00:28:39.759 --> 00:28:42.420 like lithotripsy. What should the patient expect? 00:28:42.900 --> 00:28:44.640 After lithotripsy, they need to be prepared. 00:28:45.180 --> 00:28:47.700 Hematuria is expected. It's common for a few 00:28:47.700 --> 00:28:50.200 days as the fragments pass. They might also have 00:28:50.200 --> 00:28:52.279 some minor bruising on their back or flank where 00:28:52.279 --> 00:28:54.799 the shock waves went in. We teach them to keep 00:28:54.799 --> 00:28:58.180 forcing fluids, manage their pain, and to report 00:28:58.180 --> 00:29:00.980 any signs of infection, like a fever or chills, 00:29:01.299 --> 00:29:03.640 immediately. Or if the pain gets suddenly worse. 00:29:03.799 --> 00:29:06.160 Right, because that could mean a fragment has 00:29:06.160 --> 00:29:09.079 caused a new, complete obstruction. And finally, 00:29:09.119 --> 00:29:11.759 let's revisit diet, tailored by that stone analysis. 00:29:12.900 --> 00:29:14.960 What are the key restrictions? This is such a 00:29:14.960 --> 00:29:17.279 high yield detail. The diet has to match the 00:29:17.279 --> 00:29:19.980 stone. For calcium oxalate, you reduce foods 00:29:19.980 --> 00:29:23.730 high in oxalate. Spinach, rhubarb, chocolate, 00:29:23.950 --> 00:29:27.730 nuts, tea. For uric acid. You reduce purines. 00:29:28.029 --> 00:29:31.029 So that's organ meats, shellfish, beer, and red 00:29:31.029 --> 00:29:34.230 meat. They might also need allopurinol. And for 00:29:34.230 --> 00:29:36.289 the streuvite infection stones. Prevention is 00:29:36.289 --> 00:29:38.170 all about preventing and aggressively treating 00:29:38.170 --> 00:29:40.529 UTIs. OK, let's do a quick review summary for 00:29:40.529 --> 00:29:44.150 Calculi. Immediate nursing priority, pain management. 00:29:44.319 --> 00:29:46.880 essential intervention, strain all urine for 00:29:46.880 --> 00:29:49.599 analysis, fluid goal, high intake of two to four 00:29:49.599 --> 00:29:51.880 liters a day unless there's an acute obstruction, 00:29:52.339 --> 00:29:54.759 and the acute danger is an obstruction plus a 00:29:54.759 --> 00:29:57.200 fever that equals urocepsis, which is a surgical 00:29:57.200 --> 00:30:00.039 emergency. Our final section now moves away from 00:30:00.039 --> 00:30:02.740 acute illness and into these chronic functional 00:30:02.740 --> 00:30:06.140 issues, urinary incontinence and retention. And 00:30:06.140 --> 00:30:07.960 while they aren't typically life -threatening, 00:30:08.240 --> 00:30:10.740 they have a profound impact on a patient's quality 00:30:10.740 --> 00:30:13.809 of life and dignity. They absolutely do. And 00:30:13.809 --> 00:30:16.190 they increase the risk for things like skin breakdown 00:30:16.190 --> 00:30:18.329 and infection. So let's start with the two most 00:30:18.329 --> 00:30:21.009 common types of incontinence. OK, we need to 00:30:21.009 --> 00:30:24.069 understand stress and urge incontinence. Stress 00:30:24.069 --> 00:30:26.470 incontinence is that involuntary leakage of urine 00:30:26.470 --> 00:30:29.430 when there's an increase in intra -abdominal 00:30:29.430 --> 00:30:33.690 pressure. So coughing, laughing, sneezing, exercising. 00:30:33.930 --> 00:30:36.240 And what causes that? It's caused by weakened 00:30:36.240 --> 00:30:40.000 pelvic floor muscles or a damaged urethral sphincter. 00:30:40.039 --> 00:30:42.440 It's really common after childbirth or with aging 00:30:42.440 --> 00:30:44.500 and menopause. Okay, and urge incontinence is 00:30:44.500 --> 00:30:46.039 different. It's more about the bladder muscle 00:30:46.039 --> 00:30:49.259 itself. Correct. Urge incontinence or overactive 00:30:49.259 --> 00:30:51.920 bladder is that sudden, strong, compelling desire 00:30:51.920 --> 00:30:54.839 to void that's really difficult to put off. It's 00:30:54.839 --> 00:30:57.539 caused by involuntary contractions of the detrusor 00:30:57.539 --> 00:30:59.900 muscle in the bladder wall. It's like the bladder 00:30:59.900 --> 00:31:02.740 is sending faulty signals to the brain. And then 00:31:02.740 --> 00:31:05.740 in stark contrast to that, urinary retention, 00:31:05.960 --> 00:31:08.980 not being able to empty the bladder. What defines 00:31:08.980 --> 00:31:11.680 clinically significant retention? It's usually 00:31:11.680 --> 00:31:15.839 defined by a post -void residual or PVR of greater 00:31:15.839 --> 00:31:18.460 than 200 milliliters after the patient tries 00:31:18.460 --> 00:31:20.859 to void. It's often caused by an obstruction 00:31:20.859 --> 00:31:24.140 like BPH or by impaired neurological signaling. 00:31:24.730 --> 00:31:27.230 And acute retention, where they can't go at all, 00:31:27.329 --> 00:31:30.210 is extremely painful and has to be relieved immediately. 00:31:30.589 --> 00:31:32.690 OK, let's look at the pharmacology, specifically 00:31:32.690 --> 00:31:35.410 for managing that overactive bladder with urge 00:31:35.410 --> 00:31:37.950 incontinence. The primary drug class here is 00:31:37.950 --> 00:31:41.269 anticholinergics, like oxybutynin or tolturidin. 00:31:41.490 --> 00:31:44.069 These drugs work by blocking parasympathetic 00:31:44.069 --> 00:31:46.930 nerve impulses, which relaxes that detrusor muscle, 00:31:47.190 --> 00:31:49.390 increases the bladder's capacity, and reduces 00:31:49.390 --> 00:31:51.890 the frequency of those involuntary contractions. 00:31:52.029 --> 00:31:54.150 And what's the critical nursing alert for these? 00:31:54.029 --> 00:31:57.009 drugs, especially in the elderly. Anticholinergics 00:31:57.009 --> 00:31:59.109 come with those classic systemic side effects. 00:31:59.410 --> 00:32:01.829 You can remember it as the four cants. Can't 00:32:01.829 --> 00:32:04.809 see blurred vision, can't spit dry mouth, can't 00:32:04.809 --> 00:32:07.430 stool constipation, and most critically for us, 00:32:07.690 --> 00:32:10.029 can't pee urinary retention. So you have to monitor 00:32:10.029 --> 00:32:13.130 for retention very closely. Very closely, especially 00:32:13.130 --> 00:32:16.430 in men who already have BPH. And you help them 00:32:16.430 --> 00:32:18.829 manage the annoying side effects like dry mouth 00:32:18.829 --> 00:32:21.849 with hard candy or sips of water. The sources 00:32:21.849 --> 00:32:24.390 are really clear that the cornerstone of treatment 00:32:24.390 --> 00:32:27.650 for all types of incontinence isn't drugs, it's 00:32:27.650 --> 00:32:30.769 behavioral therapy. What are the first -line 00:32:30.769 --> 00:32:33.269 nursing interventions? Behavioral therapies are 00:32:33.269 --> 00:32:36.269 absolutely the foundation. The first one is pelvic 00:32:36.269 --> 00:32:40.049 floor muscle training or Kegel exercises. This 00:32:40.049 --> 00:32:42.670 is essential for stress incontinence. And it's 00:32:42.670 --> 00:32:44.960 more than just telling them to do it, right? 00:32:45.039 --> 00:32:47.420 Oh, yeah. We have to teach them how to identify 00:32:47.420 --> 00:32:49.880 and contract the right muscles, the ones they 00:32:49.880 --> 00:32:52.279 use to stop the flow of urine or gas. And we 00:32:52.279 --> 00:32:54.279 have to emphasize they need to do them regularly, 00:32:54.599 --> 00:32:56.740 multiple times a day, to see results. What else? 00:32:57.079 --> 00:32:59.299 The other big one is timed voiding or bladder 00:32:59.299 --> 00:33:01.940 retraining. This involves setting a strict voiding 00:33:01.940 --> 00:33:04.259 schedule maybe every two hours at first, and 00:33:04.259 --> 00:33:06.319 then gradually increasing that interval to train 00:33:06.319 --> 00:33:09.170 the bladder to hold more. And, of course, managing 00:33:09.170 --> 00:33:11.490 fluid and diet by reducing bladder irritants 00:33:11.490 --> 00:33:13.809 like caffeine and alcohol. And this management 00:33:13.809 --> 00:33:16.130 is all tied to maintaining the patient's dignity. 00:33:16.529 --> 00:33:19.769 Absolutely. Beyond the behavioral stuff, we prioritize 00:33:19.769 --> 00:33:22.470 meticulous skin care to prevent incontinence 00:33:22.470 --> 00:33:25.809 -associated dermatitis. Managing this while maintaining 00:33:25.809 --> 00:33:28.269 the patient's self -worth is just a core part 00:33:28.269 --> 00:33:30.910 of compassionate nursing. Let's pivot to retention, 00:33:31.009 --> 00:33:33.250 which often means catheterization, putting us 00:33:33.250 --> 00:33:37.349 right back on high alert for CTI Joe. What's 00:33:37.349 --> 00:33:40.009 the nursing priority when an indwelling catheter 00:33:40.009 --> 00:33:43.089 is needed? Well, the immediate priority is to 00:33:43.089 --> 00:33:45.450 relieve that acute retention. But once that's 00:33:45.450 --> 00:33:48.190 done, the overarching priority shifts to CITI 00:33:48.190 --> 00:33:50.630 prevention and figuring out the underlying cause. 00:33:50.789 --> 00:33:53.670 Can you detail the strict protocols for CITI 00:33:53.670 --> 00:33:56.190 prevention we have to follow? Of course. The 00:33:56.190 --> 00:33:58.490 sources highlight several evidence -based rules. 00:33:59.069 --> 00:34:01.630 One, insertion has to be done with strict sterile 00:34:01.630 --> 00:34:04.650 technique. No exceptions. And maintenance. Maintain 00:34:04.650 --> 00:34:07.309 a closed drainage system at all times. The bag 00:34:07.309 --> 00:34:09.329 is always, always positioned below the level 00:34:09.329 --> 00:34:11.349 of the bladder to prevent backflow, and the tubing 00:34:11.349 --> 00:34:14.070 has to be free of any kinks or loops. Securement 00:34:14.070 --> 00:34:16.170 is also important. Yes, you have to secure the 00:34:16.170 --> 00:34:18.230 catheter to the patient's leg to prevent movement 00:34:18.230 --> 00:34:21.210 and urethral trauma, and you perform daily perineal 00:34:21.210 --> 00:34:23.409 care with soap and water. And the most important 00:34:23.409 --> 00:34:25.489 part. The most important role for the nurse is 00:34:25.489 --> 00:34:28.730 removal advocacy. We have to constantly assess 00:34:28.730 --> 00:34:30.670 if that catheter is still medically necessary 00:34:30.670 --> 00:34:33.170 and advocate for its prompt removal as soon as 00:34:33.170 --> 00:34:35.650 it's not. Every single day that catheter stays 00:34:35.650 --> 00:34:38.710 in, the risk of CIUTI goes up exponentially. 00:34:38.949 --> 00:34:40.969 Let's do a quick review summary for these functional 00:34:40.969 --> 00:34:43.349 problems. Okay. First -line treatment for UI 00:34:43.349 --> 00:34:46.489 behavioral therapies like Kegel exercises and 00:34:46.489 --> 00:34:49.150 timed voiding. Anti -cholinergics. They're used 00:34:49.150 --> 00:34:51.570 to treat urge incontinence, but you're on high 00:34:51.570 --> 00:34:54.769 alert for those side effects. constipation, dry 00:34:54.769 --> 00:34:57.409 mouth, blurred vision, and retention. And the 00:34:57.409 --> 00:35:00.429 priority for retention. Relieve the acute retention, 00:35:00.730 --> 00:35:03.409 address the underlying cause like BPH, and then 00:35:03.409 --> 00:35:05.889 strictly adhere to all the CIU -TI prevention 00:35:05.889 --> 00:35:08.789 protocols, especially advocating for prompt removal 00:35:08.789 --> 00:35:12.530 of the catheter. We have completed a really comprehensive 00:35:12.530 --> 00:35:15.809 high -yield deep dive into these renal and urologic 00:35:15.809 --> 00:35:18.989 priorities. We successfully navigated those three 00:35:18.989 --> 00:35:22.530 critical challenges. Fluid balance, pain management, 00:35:22.730 --> 00:35:26.269 and sepsis risk. I think we did. To synthesize, 00:35:26.349 --> 00:35:28.090 you know, we detailed the aggressive steps you 00:35:28.090 --> 00:35:30.489 have to take to fight sepsis and pilonephritis, 00:35:30.789 --> 00:35:33.469 where that CVA tenderness is your call to action. 00:35:34.030 --> 00:35:37.070 We explored the huge fluid shifts in APSGN and 00:35:37.070 --> 00:35:40.010 nephrotic syndrome, emphasizing that HTN control 00:35:40.010 --> 00:35:42.909 and meticulous skin care are just so critical. 00:35:43.090 --> 00:35:45.409 And we focused on the acute pain management for 00:35:45.409 --> 00:35:48.110 kidney stones, really hitting on NSAIs and that 00:35:48.110 --> 00:35:50.670 non -negotiable need to strain all the urine. 00:35:50.860 --> 00:35:52.659 Finally, we looked at the functional disorders 00:35:52.659 --> 00:35:55.139 reinforcing the power of behavioral modification, 00:35:55.539 --> 00:35:57.800 those Kegels, and timed voiding as the first 00:35:57.800 --> 00:36:01.280 line of defense. So as you integrate all of this 00:36:01.280 --> 00:36:03.579 information, what's the single most important 00:36:03.579 --> 00:36:05.719 conceptual link you should take away from this 00:36:05.719 --> 00:36:08.210 whole review? Well, we've seen almost every single 00:36:08.210 --> 00:36:10.190 intervention we talked about, from preventing 00:36:10.190 --> 00:36:12.869 UTIs, to avoiding another kidney stone, to managing 00:36:12.869 --> 00:36:15.949 incontinence. It's all heavily dependent on consistent, 00:36:16.170 --> 00:36:18.849 proactive patient behaviors. It's about hydration, 00:36:19.150 --> 00:36:21.349 adherence, and hygiene. It goes about empowerment. 00:36:21.650 --> 00:36:24.030 It's all about empowerment. If you can apply 00:36:24.030 --> 00:36:26.030 the concept that the nurse's role isn't just 00:36:26.030 --> 00:36:28.969 to fix the acute problem, but to empower the 00:36:28.969 --> 00:36:31.170 patient through knowledge about their daily habits, 00:36:31.670 --> 00:36:34.070 whether that's front -to -back wiping, sticking 00:36:34.070 --> 00:36:36.849 to a low oxalate diet, or just drinking their 00:36:36.849 --> 00:36:38.989 two liters of water. Then you'll understand the 00:36:38.989 --> 00:36:41.789 most essential and I think the most testable 00:36:41.789 --> 00:36:44.329 component of nursing care for this whole population. 00:36:44.849 --> 00:36:47.789 Prevention and education as treatment. That is 00:36:47.789 --> 00:36:50.690 fantastic advice. You've really distilled the 00:36:50.690 --> 00:36:52.789 critical need to know from all the noise. Thank 00:36:52.789 --> 00:36:54.610 you for sharing your sources and helping everyone 00:36:54.610 --> 00:36:56.510 prepare for success. My pleasure. We'll catch 00:36:56.510 --> 00:36:57.769 you on the next Deep Dive.