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CLIENT TEACHING GUIDE
JAUNDICE AND HEPATITIS (CONTINUED)
Diet:
Eat small, frequent, low-fat, high-calorie meals. You may be instructed to limit protein during acute phases of some types of
hepatitis. Sit down to eat to reduce pressure on your liver. Drink 8 to 10 glasses of liquids a day.
Medications:
There are several medications to treat hepatitis. Treatment depends on the type of hepatitis. It is important that you
take all your medications as prescribed by your healthcare provider.
You
Have Been Prescribed:
You
Need to Take:
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Mild confusion.
B.
Personality changes.
C.
Worsening symptoms.
D.
Tremors.
E.
Other:
Phone:
RESOURCES
Hepatitis
Hepatitis
Centers
for Disease Control and Prevention: www.cdc.gov/hepatitis
B information is available from the Hepatitis B Foundation: www.hepb.org
C information is available from the American Liver Foundation: www.liverfoundation.org
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT
TEACHING GUIDE
LACTOSE INTOLERANCE AND MALABSORPTION
PROBLEM
Lactose intolerance can cause gas, bloating, abdominal cramps, diarrhea, and nausea or vomiting. You may be able to eat small
portions without problems or be unable to tolerate any foods containing lactose.
CAUSE
erance, the body does not make enough of the enzyme or the enzyme does not work well. Lactose intolerance is very common; it
occurs when the body is not able to appropriately digest this milk sugar content and results in diarrhea.
PREVENTION/CARE
TREATMENT
Activity:
a registered dietitian to assist in your dietary plan.
Diet:
A.
Limit or stop eating foods that contain milk, lactose, whey, or casein.
B.
Lactose-controlled diets allow up to one cup of milk per day for cooking or drinking, if you can tolerate it.
C.
If you cannot tolerate any lactose, choose lactose-free foods with lactate, lactic acid, lactalbumin, whey protein, sodium
caseinate, casein hydrolysates, and calcium compounds. Read labels carefully.
D.
You may also choose kosher foods marked “pareve” or “parve,” which do not contain lactose. Read labels carefully.
E.
A low-fat diet is important if you have fat malabsorption.
F.
To help with diarrhea caused by malabsorption, avoid more than one serving a day of caffeine-containing drinks.
G.
Beverages with high sugar content, such as soft drinks and fruit juices, may increase diarrhea. Juices and fruits with high
amounts of fructose include apples, pears, sweet cherries, prunes, and dates.
H.
Sorbitol-containing candies and gums may cause diarrhea.
Yo u
have been diagnosed as having difculty digesting milk (lactose) products or having problems with absorption.
Lactose
is the sugar present in milk, and the body makes an enzyme to break down lactose. In people with lactose intol-
Follow
a lactose-free or lactose-controlled diet.
PLAN
No restrictions are required. Resume normal activities as soon as diarrhea symptoms improve. You may be sent to see
Medications:
You may need the enzyme lactase to help you digest your food. You may need vitamins and minerals if you are hav-
ing problems with malabsorption/diarrhea.
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Severe abdominal pain.
B.
Diarrhea causing dehydration.
C.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT
TEACHING GUIDE
ROUNDWORMS AND PINWORMS
PROBLEM
and threadlike. Both types of worms thrive in the intestinal tract and are very common in children. They can spread to other family
members, so the entire family needs to be treated.
CAUSE
transmitted from person to person by direct transfer of infective eggs to the mouth, or by indirect transfer through clothing, bedding, food, or other items contaminated with the eggs. Nighttime itching is one of the main symptoms of pinworms.
Roundworm
taminated unwashed hands.
PREVENTION/CARE
A.
Remove sources of infection by treating the infected person and family members.
B.
Household measures:
1.
2.
3.
chairs carefully.
C.
Practice good personal hygiene. Wash hands before handling foods and eating, and after using the toilet. Wash the anus and
genitals with warm water and soap at least twice a day. Rinse well and then wash your hands.
D.
Take a morning bath to remove most eggs. Other people should not take a bath in the same water.
E.
Keep ngers away from the mouth. Cut nails and discourage nail biting and scratching the bare anal area.
F.
Clean ngernails before meals and after bowel movements.
G.
Reduce overcrowding when possible.
H.
For roundworms, have pets treated and avoid stray animals.
Roundworms
Pinworms
and pinworms are intestinal parasites. Roundworms look like earthworms; pinworms are small, white,
live in the human rectum or colon and come out during the night onto the skin around the anus. Pinworms are
eggs enter the human body by drinking contaminated water or eating contaminated food or by transfer from con-
The
following measures help prevent the spread of worms:
Wash (132°F) or boil soiled bed sheets, nightclothes, underwear, towels, and washcloths used by infected persons.
Soak fabrics that cannot be boiled in an ammonia solution: one cup of household ammonia to 5 gallons of cold water.
After treatment, scrub toilet seats, bathroom oors, and xtures. Vacuum rugs, and clean table tops, curtains, sofas, and
TREATMENT
Activity:
Diet:
Medication:
PLAN Parasitic
infection is easily treated with medication. All family members need to be treated.
Resume normal activities after treatment is complete and symptoms improve.
No special foods are needed.
There are medications available to treat roundworm and pinworm infections. Your provider may want people who live
with you to take medications to prevent its spread.
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Reappearance of worms after treatment.
B.
New or unexplained symptoms. Drugs used in treatment may produce side effects.
C.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT
TEACHING GUIDE
ULCER MANAGEMENT
PROBLEM
ulcer may experience upper abdominal pain, heartburn, nausea, vomiting, and blood in the stools. Complications include bleeding
ulcer, perforation, and obstruction. These complications can be life-threatening.
CAUSE
type of bacteria called Helicobacter pylori and certain medications have been suggested as causing ulcers.
PREVENTION/CARE
TREATMENT
A.
If aspirin or a nonsteroidal anti-inammatory drug causes the ulcer, eliminate the drug. If you need the drug for other health
problems, discuss other options with your healthcare provider. You may need to stop the medicine or take a lower dose.
B.
Avoid caffeine, colas, alcohol, and chocolate because they may increase acid production.
C.
Stop smoking: It slows the ulcer’s healing and increases its chance of coming back.
D.
Be sure to tell healthcare providers about your history of ulcer and gastrointestinal pain if you need new prescriptions or are
sent to the hospital.
E.
Review all of your medications, over-the-countermedications, and herbal products for possible causes or ulcer irritants.
Activity:
ulcer is a sore in the lining of the stomach or intestine that occurs in areas exposed to acid and pepsin. People with
Although
the exact cause of ulcer formation is not completely understood, the process appears to involve excess acid. A
Modify
your lifestyle to include health practices that prevent recurrences of ulcer pain and bleeding.
PLAN
Exercise daily, plan rest periods, avoid fatigue, and learn to cope with or avoid stressful situations.
Diet:
A.
Eat a well-balanced diet with high-ber content.
B.
Eat meals at regular intervals. Frequent small feedings are unnecessary. Avoid bedtime snacks.
C.
Eliminate foods that cause pain or distress; otherwise, your diet is usually not restricted. Examples of foods that cause worse
pain are:
1.
Peppermint.
2.
Spicy food.
3.
Alcohol.
D.
Avoid extremely hot or cold food or uids, chew thoroughly, and eat slowly while relaxed for better digestion.
Medications:
A.
Acid blockers and medicines called proton pump inhibitors (PPIs) reduce stomach acid.
B.
You may need to take antibiotics to ght H. pylori infection.
C.
Other medications may be prescribed to coat the ulcer area. Antacids can be taken during the ulcer treatment, but should not
be used 1 hour before or 2 hours after the ulcer treatment medications because antacids can interfere with absorption.
D.
Take the entire prescription: Do not stop when you feel better.
E.
If you have been prescribed metronidazole (Flagyl) or clarithromycin, you may notice a metallic taste in your mouth.
F.
Alcohol (including wine) should be avoided when taking Flagyl. The interaction can cause skin ushing, headache, nausea, and
vomiting.
G.
If you are prescribed bismuth, you may notice black bowel movements (BMs).
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Worsening symptoms while taking your medication.
B.
Vomiting that is bloody or looks like coffee grounds.
C.
Tar-colored or “grape jelly” BMs. If this occurs, bring a stool sample to the ofce.
D.
Diarrhea and/or severe pain despite treatment.
E.
Unusual weakness or paleness.
F.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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C H A P T E R
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GENITOURINARY
Kristina
Potts and Nancy Pesta Walsh
BENIGN
PROSTATIC HYPERTROPHY
GUIDELINES
DEFINITION
A.
Benign prostatic hypertrophy (BPH) is enlargement of the
prostate gland that constricts the urethra, causing urinary
symptoms. BPH is not believed to be a risk factor for prostate cancer. BPH occurs primarily in the central or transitional
zone of the prostate, whereas prostate cancer originates primarily in the peripheral part of the prostate (Figure 12.1).
B.
The voiding dysfunction that results from prostate enlarge-
ment and bladder outlet obstruction is termed lower urinary
tract symptoms (LUTS).
INCIDENCE
A.
BPH increases progressively with age. The prevalence of
prostatic hyperplasia increases from 8% in males aged 31 to
40 years to 60% at age 60 and 80% in males 80 years and older.
PATHOGENESIS
A.
The exact cause is unknown; BPH may be a response to
the androgen hormone. The process of aging and the presence of circulating androgens lead to the development of
BPH. Hyperplasia, in which the normally thin and brous
outer capsule of the prostate becomes spongy and thick, and
the contraction of muscle bers cause pressure on the urethra. This condition requires the bladder musculature to work
harder to empty urine.
PREDISPOSING
A.
Advancing age.
B.
Race: Black males younger than 65 years may need treat-
FACTORS
ment more often than White males.
C.
Genetic predisposition: Increases with a positive family
history of BPH with moderate to severe LUTS.
D.
Obesity.
E.
Diabetes.
F.
High levels of alcohol consumption.
G.
Physical inactivity.
COMMON
A.
COMPLAINTS
The clinical manifestations of BPH are LUTS that typically
appear slowly and progress gradually over a period of years.
B.
Difculty starting urine ow.
C.
Dribbling at end of urination.
D.
Bladder does not feel like it completely empties.
E.
Frequent urination.
F.
Nocturia.
OTHER
SIGNS AND SYMPTOMS
A.
Obstructive symptoms:
1.
Hesitancy.
2.
Diminution in size and force of urinary stream.
3.
Stream interruption (double voiding).
4.
Urinary retention.
5.
Straining/Valsalva maneuver to fully empty the
bladder.
B.
Irritative voiding symptoms:
1.
Urgency.
2.
Frequency.
3.
Nocturia.
4.
Painless hematuria: an early symptom; may also indi-
cate malignancy.
C.
Severe late symptoms with untreated BPH:
1.
Acute urinary retention.
2.
Recurrent urinary tract infections (UTIs).
3.
Hydronephrosis.
4.
Loss of renal concentrating ability.
5.
Systemic acidosis and renal failure.
FIGURE
12.1 Benign prostatic hyperplasia (BPH). Flow
of urine with a normal prostate (A) and with an enlarged
prostate/BPH (B).
The
contributions of Cheryl A. Glass, Debbie Gunter, and Angelito Tacderas to this chapter in prior editions are acknowledged here.
SUBJECTIVE
A.
Have the client complete the American Urological
DATA
Association Symptom Score (AUASS) assessment tool at each
visit to track symptoms. The AUASS (Table 12.1) is used to
assess the severity of symptoms of BPH.
B.
Review the onset, duration, and course of symptoms. The
AUASS assessment tool can be used to quantitatively assess
BPH symptoms over time.
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TABLE
12: GENITOURINARY GUIDELINES
12.1 AMERICAN UROLOGICAL ASSOCIATION SYMPTOM SCORE FOR BENIGN PROSTATIC
HYPERTROPHY
CLIENT NAME:
TODAY’S DATE:
(Circle One Number on
Each Line)
Over the past month or so, how
often have you had a sensation
of not emptying your bladder
completely after you finished
urinating?
During the past month or so, how
often have you had to urinate
again less than 2 hours after
you finished urinating?
During the past month or so,
how often have you found
you stopped and started
again several times when you
urinated?
During the past month or so, how
often have you found it difficult
to postpone urination?
During the past month or so, how
often have you had a weak
urinary stream?
During the past month or so, how
often have you had to push or
strain to begin urination?
Not at All Less Than One
Time in Five
Less Than Half
the Time
About Half
the Time
More Than
Half the Time
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
Almost
Always
None Once Two Times
Three
Times
Four Times
CLIENT NAME:
TODAY’S DATE:
(Circle One Number on
Each Line)
Not at All Less Than One
Time in Five
Less Than Half
the Time
About Half
the Time
More Than
Half the Time
Over the past month, how many
times per night did you most
typically get up to urinate from
the time you went to bed at
0 1 2 3 4 5
night until the time you got up
in the morning?
Add the score for each number above and write the total in the space to the right. TOTAL: ___________
SYMPTOM SCORE: 1–7 (Mild); 8–19 (Moderate); 20–35 (Severe)
Quality of Life
Not at All Pleased Mostly
Satisfied
Mixed Mostly
Dissatisfied
How would you feel
if you had to live
with your urinary
condition the
way it is now, no
0 1 2 3 4 5
better, no worse,
for the rest of
your life?
American Urological Association (AUA) Education and Research Inc.
Source:
Five or More
Times
Almost
Always
Unhappy Terrible
6
BENIGN PROSTATIC HYPERTROPHY
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C.
Does the client have signs of a UTI?
D.
Is there any blood in the urine or pain in the bladder
region? (Evaluate bladder tumor or calculi.)
E.
Does the client have new symptoms such as bone or back
pain, loss of appetite, or weight loss (rule out cancer)?
F.
Review the client’s history for medical illness, including
diabetes and neurologic problems.
G.
Review previous urinary problems, surgeries, infections,
treatments, success of treatments, and testing.
H.
Review the client’s history of sexual dysfunction, any new
sexual partners, and sexually transmitted infections (STIs).
I.
Review the client’s history of urethral trauma, urethritis,
or urethral instrumentation that could have led to urethral
stricture.
J.
Review medications, both prescription and over-the-coun-
ter drugs, including sinus or cold products, anticholinergic
drugs (impair bladder function), and sympathomimetic drugs
(increase outow resistance).
K.
Review family history of BPH and prostate cancer.
L.
Review uid intake, especially caffeinated/carbonated
drinks.
M.
Evaluate how bothersome the symptoms are to the client’s
quality of life:
1.
How often does the client have interrupted sleep to get
up to go to the bathroom?
2.
How often does the client urinate?
3.
Does the client have to wear an absorptive underwear
pad?
PHYSICAL
A.
Check temperature (if indicated), blood pressure (BP), and
EXAMINATION
weight (if indicated).
B.
Inspect:
1.
Inspect general appearance for discomfort or acute dis-
comfort with urinary retention.
2.
Consider having the client void: Normal urination for
a male is the ability to empty the bladder of 300 mL of
urine in 12 to 15 seconds.
3.
Examine the urethral meatus for discharge.
4.
Retract foreskin (if present) and assess for hygiene and
smegma.
5.
Check the shaft of the penis, glans, and prepuce for
lesions.
6.
Check inguinal and femoral areas for bulges or her-
nias; have the client bear down and cough and reexamine
them.
7.
Perform a neurologic examination (evaluate sensory
and motor decits).
C.
Palpate:
1.
Palpate the abdomen for masses or bladder distention.
2.
Palpate lymph nodes in the groin for enlargement.
3.
Check costovertebral angle (CVA) tenderness.
4.
Palpate the testes and epididymides for inammation,
tenderness, and masses.
5.
Palpate the scrotum for hydrocele or varicocele.
D.
Digital rectal examination (DRE): Use the index nger of
the dominant hand for the DRE.
1.
Note sphincter tone, nodules or masses, and tender-
ness. Decreased anal sphincter tone or the lack of muscle
reex may indicate an underlying neurologic disorder.
2.
Palpate the two lateral lobes of the prostate gland
and its median sulcus for irregularities, nodules, induration, swelling, or tenderness just above the prostate anteriorly; determine whether the rectum lies adjacent to the
peritoneal cavity. If possible, palpate this region for peritoneal masses and tenderness.
3.
The U.S. Preventive Services Task Force (USPSTF) does
not recommend DRE as a screening test due to lack evidence on its benets.
DIAGNOSTIC
A.
Urinalysis: Evaluate for infection and hematuria.
B.
Urine culture if indicated (clients with BPH are more sus-
TESTS
ceptible to UTIs).
C.
Optional studies:
1.
Prostate-specic antigen (PSA): Reference ranges
vary by age and ethnicity and may be elevated with
BPH. Recommended in males with at least a 10-year life
expectancy.
2.
Urodynamic testing, including maximal urinary ow
rate.
3.
Postvoid residual (PVR; as shown by in–out catheter-
ization, radiography, or ultrasound).
4.
Cystourethroscopy: Not recommended in the initial
routine evaluation visit (may be needed later depending
on workup for planning for surgical therapy).
D.
The American Urological Association (AUA) holds that the
routine measurement of serum creatinine levels is not indicated in the initial evaluation.
DIFFERENTIAL
A.
Other obstructive causes: prostate cancer, urethral obstruc-
DIAGNOSES
tion, urethral stricture, and vesical neck obstruction.
B.
Neurogenic bladder.
C.
Cystitis.
D.
Prostatitis.
E.
Bladder calculi.
PLAN
A.
General interventions:
1.
Have the client complete a 24-hour voiding chart with
assessment of frequency and volume.
2.
Any client with other than mild symptoms needs refer-
ral to a urologist to discuss treatment options (surgery or
drugs).
3.
Monitor the client with mild symptoms every 3 to
6 months to determine the progression of symptoms.
Imaging studies are not routinely necessary in typical
cases of BPH unless there is hematuria, an elevated creatinine, or another indication.
4.
Treat concurrent UTI and STIs.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Prostatic Hypertrophy/Benign.”
1.
Client should be instructed about the hypotensive
effect, asthenia, nasal congestion, and effect on ejaculation of the long-acting alpha-1 antagonists. The hypotensive effects can be potentiated by concomitant use of
phosphodiesterase-5 (PDE5) inhibitors sildenal (Viagra),
tadalal (Cialis), or vardenal (Levitra).
2.
Alpha-1 antagonists have been associated with intra-
operative oppy iris syndrome. Clients need to discuss
using these medicines with their ophthalmologist before
eye surgery (e.g., cataract).
C.
Pharmaceutical therapy:
1.
Five long-acting alpha-1 antagonists are Food and
Drug Administration (FDA)-approved for treatment of
BPH. Two are selective alpha-1 blockers and three are nonselective alpha-1 blockers.
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12: GENITOURINARY GUIDELINES
a.
Terazosin (Hytrin) 1 to 20mg/d: side effect increases
hypotensive effect with PDE5 inhibitor; requires dose
titration to minimize side effects (nonselective).
b.
Doxazosin (Cardura) 1 to 8 mg/d: side effect
increases hypotensive effect with PDE5 inhibitor; requires dose titration to minimize side effects
(nonselective).
c.
Tamsulosin (Flomax) 0.4 to 0.8 mg/d: side effect
decreases ejaculate volume (selective).
d.
Alfuzosin (Uroxatral) 10mg/d: generally does not
cause ejaculation problems.
e.
Silodosin (Rapao) 8 mg/d: side effect may produce
retrograde ejaculation (selective).
2.
Prazosin (Minipress), a short-acting alpha-1 antago-
nist, is approved for treatment of hypertension (HTN). It
improves urine ow rates and may be considered in a client with HTN and urinary symptoms.
3.
Two 5-alpha-reductase inhibitors (ARIs) are
FDA-approved for BPH with an enlarged prostate and
bothersome LUTS. These medications help reduce the
risk of acute urinary retention and the need for surgical
interventions. The major side effects of these drugs are
decreased libido and ejaculatory or erectile dysfunction.
a.
The FDA has issued safety information on the use
of 5-ARIs due to an increased risk of being diagnosed
with a more serious form of prostate cancer (high-grade
prostate cancer).
b.
Clients who are, or may become, pregnant should
not handle the 5-ARIs. The inhibitors are pregnancy
category X drugs known to cause birth defects.
c.
Finasteride (Proscar) 5 mg/d.
d.
Dutasteride (Avodart) 0.5 mg/d.
e.
Dutasteride–tamsulosin (Jalyn): Each capsule con-
tains 0.5 mg dutasteride and 0.4 mg tamsulosin.
4.
Dual-drug combination with an alpha-blocker and a
5-ARI can be used if a single agent is not effective.
5.
There are no herbal supplements that have been
approved by the FDA for treatment of BPH; however, clients may report taking saw palmetto. The AUA does not
endorse supplements.
FOLLOW-UP
A.
See the client in 2 to 3 weeks to monitor symptoms after
specialty referral.
B.
The concept of “watchful waiting” may be appropriate for
clients with mild symptoms. The client should be seen yearly
for evaluation and an examination.
C.
PSA detects BPH more commonly than cancer, and the
USPSTF current recommendations suggest that screening be
implemented as a shared decision between the client and the
healthcare provider. The USPSTF advises routinely discussing
the desire for screening of males between the ages of 55 and
69, have a family history of prostate cancer, ofAfrican descent,
or oflower socioeconomic status. The Task Force does not recommend screening for males above 70 years old.
CONSULTATION/REFERRAL
A.
Refer to a urologist for any complicated LUTS, including:
1.
History of prostate cancer.
2.
Elevated PSA.
3.
Urethral stricture.
4.
Spinal cord injury.
5.
Stroke.
6.
Recurrent/persistent UTI.
B.
The presence of microscopic hematuria requires an evalu-
ation of the complete urinary system and needs a referral to a
urologist.
C.
Refer for procedures after failed medication therapy.
1.
Minimally invasive surgical therapies should be used
in a select client group, particularly those that place importance on preserved sexual and continence function, rather
than urinary improvement.
a.
Transurethral microwave therapy.
b.
Transurethral incision of the prostate.
c.
Transurethral vaporization of the prostate.
d.
Laser enucleation.
e.
Laser therapies.
f.
Prostatic urethral life.
g.
Water vapor thermal therapy.
h.
Photoselective vaporization of the prostate.
2.
Surgical therapies:
a.
Transurethral resection of the prostate (TURP) is
considered the gold standard for surgical treatment
of BPH. Sexual dysfunction may occur after a TURP,
including decreased libido, impotence, and ejaculatory
difculties. Balloon dilation may be used to reduce
symptoms; however, relapse is common.
b.
Open prostatectomy.
c.
Simple prostatectomy.
INDIVIDUAL
A.
Geriatrics:
1.
CONSIDERATIONS
Older clients require special attention because their
symptoms may be poorly expressed or confusing.
RESOURCES
Adult
Pediatric Urology & Urogynecology: www.adult pediatricuro.com
American
National
Urological Association (AUA): www.auanet.org
Kidney Urologic Diseases Information Clearing-house
(KNUDIC): kidney.niddk.nih.gov
BIBLIOGRAPHY
American Urological Association. (2010, revised 2018). American
Urological Association guideline: Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia. https
://www.auanet.org/guidelines/benign-prostatic-hyperplasia(bph)-guideline#x8215
American Urological Association. (2010, revised 2018). American Urological
Association guideline: Management of benign prostatic hyperplasia (BPH).
https://www.auanet.org/guidelines/benign-prostatic-hyperplasia(bph)-guideline
Associates in Urology. (n.d). Patient questionnaire: AUA symptom score
(AUASS). https://bsci-prod2-origin.adobecqms.net/content/da
m/bostonscientific-anz/patients/downloads/Enlarged_Prostate_
Symptom_Score_Questionnaire.pdf
Christidis, D., McGrath, S., & Perera, M. (2017). Minimally invasive surgi-
cal therapies for benign prostatic hypertrophy: The rise in minimally
invasive surgical therapies. Prostate International, 5(2), 41–46. https://
doi.org/10.1016/j.prnil.2017.01.007
Deters, L. A. (2019, January 15). Benign prostatic hypertrophy. Medscape.
emedicine.medscape.com/article/437359-overview
What Is Screening for Prostate Cancer?. (2019). CDC. https://www.cdc.
gov/cancer/prostate/basic_info/screening.htm
CHRONIC KIDNEY DISEASE IN ADULTS
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CHRONIC
KIDNEY DISEASE IN ADULTS
DEFINITION
A.
Chronic kidney disease (CKD) is specically dened as
follows:
1.
Persistent and usually progressive reduction in glo-
merular ltration rate (GFR) less than 60mL/min/1.73m2.
and/or
2.
Albuminuria: More than 30mg of urinary albumin per
gram of urinary creatinine CKD is a disorder that leads
to progressive kidney damage from a variety of causes,
including diabetes, hypertension (HTN), cardiovascular
(CV) disease, urinary obstructions, prolonged use of nephrotoxic medications, and inherited diseases such as polycystic kidney disease. Associated comorbidities of CKD
include renal osteodystrophy, anemia, metabolic acidosis,
and malnutrition. Early recognition of CKD as well as treatment of complications can improve long-term outcomes.
STAGES
A.
OF CHRONIC KIDNEY DISEASE
Stage 1 disease is dened by a normal GFR (>90 mL/
min/1.73m2) and persistent albuminuria.
B.
Stage 2 disease is a GFR between 60 and 89 mL/
min/1.73m2 and persistent albuminuria.
C.
Stage 3 disease is a GFR between 30 and 59 mL/
min/1.73m2.
D.
Stage 4 disease is a GFR between 15 and 29 mL/
min/1.73m2.
E.
Stage 5 disease is a GFR of less than 15mL/min/1.73m
2
or
end-stage renal disease (ESRD).
INCIDENCE
A.
Kidney disease is the ninth leading cause of death in
the United States. It is estimated that 15% of Americans are
living with CKD. It is estimated that 80,000 new cases of
nondialysis-dependent CKD are diagnosed annually; the incidence of CKD and ESRD has doubled every decade since 1980.
The number of clients enrolled in the ESRD Medicare-funded
program has increased from approximately 10,000 beneciaries in 1973 to 517,776 as of December 31, 2016. Those who
live with ESRD are 1% of the U.S. Medicare population but
account for 7% of the Medicare budget. More than 100,000 clients in the United States are on the kidney transplant list, yet
in 2017 there were just over 21,000 donor organs available for
transplant. The need for donor kidneys in the United States is
rising at 8% per year.
B.
CKD is more common in people aged 65 years or older
(38%) than in people aged 45to 64 years (12%) or 18to 44
years (6%).
C.
CKD is slightly more common in females (14%) than in
males (12%).
D.
CKD is more common in non-Hispanic Black adults (16%)
than in non-Hispanic White adults (13%) or non-Hispanic
Asian adults (13%).
E.
About 14% of Hispanic adults have CKD.
F.
CKD prevalence is greater among persons with diabetes
than among those without diabetes (40.2% vs. 15.4%) and
among persons with CV disease than among those without
CV disease (28.2% vs. 15.4%). CKD is higher among persons
with HTN than among those without HTN (24.6% vs. 12.5%).
PATHOGENESIS
A.
Blood from the renal arteries and their subdivisions is
delivered to the glomeruli. The glomeruli form an ultraltrate,
nearly free of protein and blood elements, which subsequently
ows into the renal tubules. The tubules reabsorb and secrete
solute and/or water from the ultraltrate. The nal tubular
uid, the urine, leaves the kidney, draining sequentially into
the renal pelvis, ureter, and bladder, from which it is excreted
through the urethra. The causes of CKD are traditionally classied by which portion of the renal anatomy is most affected
by the disorder.
1.
Vascular disease: Vascular disorders of the kidneys may
involve partial or complete occlusion of large, medium, or
small renal vessels.
a.
Renal artery stenosis: narrowing or blockage of an
artery to the kidneys.
b.
Renal artery thrombosis: a blood clot in a renal artery.
c.
Renal vein thrombosis: a bulging, weak area on the
wall of a renal artery.
d.
Atheroembolic renal disease: when a piece of plaque
from a larger artery breaks off and travels through the
blood causing blockage to the small renal arteries.
e.
Benign hypertensive arteriolar nephrosclerosis
results when chronic HTN damages small blood vessels, glomeruli, renal tubules, and interstitial tissues.
Glomerulosclerosis is a severe microvascular or small
vessel kidney disease caused by diabetes and uncontrolled HTN in which theglomerular function of blood
ltration is lost as brous scar tissue replaces the glomeruli. Loss of glomerular function leads to proteinuria,
hematuria, HTN, and nephrosis, with variable progression to ESRD. Proteinuria occurs due to changes
to capillary endothelial cells, the glomerular basement
membrane (GBM), or podocytes, which normally lter
serum protein selectively by size and charge.
2.
Tubular and interstitial disease: As with vascular dis-
ease, chronic tubulointerstitial nephritis (CTIN) can be
primary or secondary to glomerular damage and renovascular disease. CTIN arises when chronic tubular insults
cause gradual interstitial inltration and brosis, tubular atrophy and dysfunction, and a gradual deterioration of renal function, usually over years. Causes of CTIN
are immune disorders, infections, reux or obstructive
nephropathy, and drugs. Analgesic abuse nephropathy
(AAN) is a type of CTIN caused by cumulative lifetime
use of large amounts of certain analgesics such as nonsteroidal anti-inammatory drugs (NSAIDs).
PREDISPOSING
A.
Diabetes.
B.
HTN.
C.
CV disease.
D.
Chronic use of analgesics such as NSAIDs.
E.
Autoimmune disorder.
F.
Polycystic kidney disease.
G.
Urinary tract obstructions such as benign prostatic hyper-
FACTORS
trophyor kidney stones.
H.
Recurrent urinary tract infections.
I.
Older than 60 years.
J.
African American, Native American, or Hispanic ethnicity.
K.
Smoking.
L.
Exposure to toxins.
M.
Family history of kidney disease.
COMMON
A.
COMPLAINTS
In CKD stages 1 and 2, there are usually no presenting
complaints; however, HTN is usually present. CKD is usually
identied through routine screening of kidney function and
urine tests for microalbumin.
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