NR 507 PATHOPHYSIOLOGY WEEK 4 TD2 Alterations in Renal Function Discussion Part Two (NR507)

Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK 4 TD2 Alterations in Renal Function Discussion Part Two (NR507) Week 4: Alterations in Renal Function - Discussion Part Two Loading... Discussion This week's graded topics relate to the following Course Outcomes (COs). 1 Analyze pathophysiologic mechanisms associated with selected disease states. (PO 1) 2 Differentiate the epidemiology, etiology, developmental considerations, pathogenesis, and clinical and laboratory manifestations of specific disease processes. (PO 1) 3 Examine the way in which homeostatic, adaptive, and compensatory physiological mechanisms can be supported and/or altered through specific therapeutic interventions. (PO 1, 7) 4 Distinguish risk factors associated with selected disease states. (PO 1) 5 Describe outcomes of disruptive or alterations in specific physiologic processes. (PO 1) 6 Distinguish risk factors associated with selected disease states. (PO 1) 7 Explore age-specific and developmental alterations in physiologic and disease states. (PO 1, 4) Discussion Part Two (graded) Responses Lorna Durfee 5/23/2016 1:47:48 PM Discussion Part Two Dr. Brown and Class: What is your differential diagnosis? Urinary Calculi. Nephrolithiasis tAh i5g6h-.y Ueapro-no lfdu rfethmearl eq uceosmtieosn iinngto, sthhee ctelilnlsi cy ocuo mthpalat isnhien gh aosf ainnt eurrmgeit taelnwt asyesv etore g poa tion tthhea tr ersatdrioaotmes afrnodm th tahte sfhlaen sko tmoe tthime egsr osiwne aantsd asnodm feeteimlse nsa tuos tehoeu isn. nAe r urinalysis provides traces of blood, a few white blood cells, and no bacteria. hTaevsets m: Uacrrionsacloypsiics sohr omwisc rfoeswco wphici thee bmloatoudr icae, lblsu,t ttrhaec uer binloe omda y= bhee mnoartmuarli.a Torh emrei ccraonh beem paytuurriiaa w ainthdo nuot bbaacctteerriaia. . I f Pthaetireen itss pwyiuthri na eapnhdr ofoliuthl-isamsise lclianng 2ur0i1n4e) fever, there can be an infection. If there is suspicion of crystalline substances in the sediment, further testing will be necessary (Preminger, X-ray: Slightly dilated ureter. Discuss in detail the pathophysiology of each item in your differential and how it might fit in describing this case. Pathophysiology of following items: Flank to groin pain into the thigh, severe and intermittent, urgency, sweats, nausea. Preminger (2014) relates that calculi can remain in the renal parenchyma or renal pelvis or passed to the ureter or bladder. An abrasion passing and trauma in the ureter and bladder walls can cause pain. Calculi, when lodged in the ureter, can cause obstruction and decrea sferdo mur ain set oflnoew . They can cause hydroureter or dilation of the ureter, and hydronephrosis, or a swelling in the kidney due to the build-up of urine (Preminger, 2014). lCoodmgemd oinn athreea usr oetfe trhoapte sltvoinc ejsu ngcetti olond. g eAdn ayr ec ainlc tuhlei tuhraett earroep semlvailcl ejru anrcet iloink ealnyd t oth pea dssis ttharl ouurgehte rth. e C saylsctuelmi t.h aWt hhaevne t hae dreia ims eatne ro bosf tgrurecatitoenr ,t hthaenr e5 ims ma can be rdeencarle afusen cinti othne ( Pfirletrmatiinogne or,f 2th0e1 4g)l.o meruli. With swelling in the kidney there is an increased glomerular pressure and decline in blood flow and then sPyremmpitnogmesr t(h2a0t1 a4c)c toemllsp auns yt htahti ss tcoonned rietimona ianrien gse ivne trhee p raeinna tlh paet livsi as cacroem npoat nsyiemd pbtyo mnaautisce au.n Ttihl ethree yc acna uasleso o bbest rvuocmtiiotnin agn tdh/aotr u isnufeaclltyio onc. c uTrhse w shigenns c aanlcdu li pWashse nin tthoe trhee i su rpeatienr ionr tchaeu fslea nokb sotrru kcitdionney. aTnhde rfaedeilaintegs oafc proasins tihs ed aubed toom reenna, li tc oisl iscu tghgaet sitsi veex corfu ac iuarteintegr aaln odr i rse innatel rpmelivttiecn ot.b sTtrhuec ptiaoinn. c Iofn tthine upeasi nin r aad ciyatcelse . icnotuol dth ael sgor obien aa lbolnagd dthere cuarlectuelru, sth (ePrree mcainn gbeer a, 2lo0w14e)r. u r eteral obstruction. If the pain is suprapubic, it can be a distal ureteral, ureterovesical calculus. It uNseupahllryo plirtehsieansti sw: i tChu rrehnaanl, cAorliocn asonnd &he mPraetmuriinag. e Or (th2e0r1 5p)a trieelnattse mthaayt rperneasel natn wd iutrhe vteargaul es taobndeos marien asle epna imn,o asctu ctoem abmdoonmlyin saele fnla innk p priamina,r nya cuasreea. . P Tahtieernet sis taylspoe su irnincaluryd eu rcgaelcnicuym a npdh ofsrepqhuaeten,c uyr iacn adc didif,f sictruulvtyit eu,r iannadti ncygs. tAinpep. r oTxhiem tahteeolyry 8 i0s pthearct esntot noef fpoartmieantti owni thha tphpies ncso wndhietino nth hea svoel ucballec imumat esrtioanl e(sc.a lOcituhmer stone ionxcarleaatsee) swuipthe rtsiamtuer.a tTehs itsh pe ruorcienses, hanapdp tehniss baet gsiintess tohfe ecpryitshtealli afol rimnjautriyo,n a pnrdo tchees sc.r yTshtaelsse m crayys ctaaluss aer eth aisn.c h Aorneodt htoe rc tohleleocrtyi oins tdhuact tsst,o anneds tahnedir t hsiezier fwoirlml ation cbaelgciinu mat othxea lraetnea al nmde pdhuollsaprhya itnet edresptiotsiuitm o.n Ctoapl coiuf mth ipsh polsapche aatne dc rtyhsetna lrse mfoarmin, aitnta tchhee idn tteor sthtieti upmap ialnlad (tChuenrh eaxnt reut daeld., f2r0o1m5 )t.h eP rreemnailn pgaepr iallnad. CTuhreh carny (s2ta0l1s5 o)f tseulgl guess tth tahta at popbreosxitiym aamteolyn g8 wpeormceennt hoaf sw ao pmaertn t wo ipllla hya ivne tahte l efoarsmt oantieo nst oonf eth bey s tthoen easg e(P orfe m70in. g Tehr e&se C sutorhnaens ,w 2i0ll1 c5o).n tGaionu cldal acniudm D oyxear l(a2te0.1 1T)h teeyll aulss oth at sotfo tnhees uinre tthere, kthidenree ya roer ibnltaedndsee rs apraes massy omfp ptaoimn aitni ct hfere fqlaunekn ttlhya. t Sraodmiaetteims ienst ofl athnek gpraoiinn othccaut rcsa nb elcaasut suen toifl tdhiest setnotnioen c iann tbhee rreemnaolv ceadp.s uTlhe.i s Wpaiitnh coobmsterus cftrioomn the ureter contractions which is trying to force the stone out. There can be a rapid pulse, nausea, and vomiting (Gould and Dyer, 2011, p. 455). The x-ray comes back, and there is nothing abnormal except a slightly dilated ureter. Does this change your differential or narrow it? iIn wveosutlidg antoiot nc.h aTnhgee uthsee odfi faf enroennt-icaol.n tTrahset hdeillaicteadl CurTe tcearn g diveetes cat dloecfaintiiotinv ea nsdy mdepgtoreme tohfa ot biss trreulcattieodn .t o H uoriwnaervye rc,a ilfc tuhliis. pTahtiies npta htiaesn ht ande emdsa nfyu rCthTe rs cans, there is a concern for radiation exposure (Preminger, 2014). oHpoiowi dws,o Iu lwdo yuoldu ttrrye athte t hreec pomaimn einn dtahtiiso nca osfe ?st a Artsin tgh elo Cwe natnedr sg fooirn gD sisloeaws ew Choenn tirto cl oamnde sP troe voepnitoiiodn mhaevdeic Gatuioidne. l iIn weso fuoldr Pprroevfeidr enrost wtoh eunse i to cpoiomidess taon d pwraenfet rt oa nptrio-ivnifdlea mqumaanttoitryie ns.e e Idf eodp fioorid tsh ea rdeu troa tbioe nu soefd p, atihne y(T nheee dC eton tbeers a fto trh eD liosewaesset Cpoonsstribolle a dnods Pe raenvde nthtieo nu,s 2e 0o1f6 i)m. mediate-release opioids. I would only pPareinm rienlgieefr a(2n0d1 a4r)e satpapterso pthraiat tter.e aAtmn eanntt ioefm reetniacl ccooullidc iasl swoi bthe tuhsee uds teo osft oopp itohied vs osmucihti nags .m Aolrtphhoiungeh, oinr cforera rsaipnigd folunisdest ,h faesn btaeneynl .t r aHdei tsiotantaelsl yb outshe da riet uhsaesd n foot r oprbosvtreunc ttioo nsp ae eudre ttheera pl asstseangt ec aonf cbael cuusleid. aInf dth teh ecnal creumli odvoa ln ootf pthaes sc walictuhliin ( 6P rteom 8i nwgeeerk, s2,0 t1h4e)n. removal is necessary. When there is an immediate need for References Curhan, G. C., Aronson, M. D., & Preminger, G. M. (2015). Diagnosis and acute management of suspected nephrolithiasis in adults. Retrieved from Gould, B. E., & Dyer, R. M. (2011). Urinary System Disorders. In Pathophysiology for the health professions (4th ed., p. 450-455). Preminger, G. M. (2014). Urinary Calculi (Nephrolithiasis). In Merck Manual online. Retrieved from The Centers for Disease Control and Prevention. (2016). Guideline Information for Providers. Retrieved from Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., & Denberg, T. D. (2014). Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians. Annals Of Internal Medicine, 161(9), 659-667. doi:10.7326/M13-2908 Liberty Neoh 5/24/2016 7:35:48 PM Discussion 2 Dr. Brown and Class, Based from the symptoms presented, the patient has kidney stones. Kidney stones can cause flank pain, typically there are acute spasms of severe pain, radiation of the pain to the groin, and then testicles in men and labia in women, nausea, and vomiting. The dilated ureter from the x ray result may be due to the obstruction caused by kidneys stones (Skolarikos, Dellis, & Knoll, 2015). Other differentials may include gallstones, irritable bowel syndromes, and other gastrointestinal disturbances. Most common complaints are abdominal pain. Patients’ health histories must be obtained in detail and needs to include accompanying signs such as abdominal pain relieved by defecation, pain associated with looser stools, pain associated with more frequent stools, sensation of incomplete rectal emptying, passage of mucous, and visible abdominal distension (Kirk et al, 2011). According to Resorlu and his colleagues (2013), “shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PNL), and retrograde intrarenal surgery (RIRS) are the three main modalities for the management of upper urinary stone disease”. Treatments are usually performed in outpatient settings. References Kirk, G., Kennedy, G., McKie, L., Diamond, T., & Clements, B. (2011). Preoperative symptoms of irritable bowel syndrome predict poor outcome after laparoscopic cholecystectomy. Surgical Endoscopy, 53. doi: 10.1007/s Resorlu, B., Unsal, A., Ziypak, T., Diri, A., Atis, G., Guven, S.,…Oztuna, D. (2013). Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous ephrolithotomy for treatment of medium-sized radiolucent renal stones. World Journal of Urology, 31. doi: 10.1007/s Skolarikos , A., Dellis, A., & Knoll, T (2015). Ureteropelvic obstruction and renal stones: etiology and treatment. Urolithiasis, 43. doi: 10.1007/s Brooke Lobianco reply to Liberty Neoh 5/29/2016 3:33:42 PM RE: Discussion 2 LiberTtyh, ank you for your post! Just to talk a little bit more in depth regarding the types of stones; most kidney stones are radiopaque these are the sctaolcnieusm a rceo fnotuanindi ning 5st6o n- e6s1;% (c aolfc aiudmul tosx, aclaaltcei uamnd p chaolscpiuhmat ep hino s8p -h a1t8e%) w",i (thF rtahses emttoos ta ncdo mKmoholns tbaeditn, g2 0th1e1 )m oxalate stones. "Calcium oxalate and cUryrsitci naec iodn slyto inne sa,b coruyts 1ti%ne ,o af nadll satduurvltist"e,, (aFrera tshsee tsttoo nanesd tKhaoth alsrtea rdatd, i2o0l1u1ce).n Tt.h "eUseri cst aocnieds satroen neso ta vree rfyo ucnodm imn o9n -, 1th7e%y doef vaedluolpts w, shteunrv tihtee rien i2s t-o4 % Amsu cwhe u krnico awc igdo iunt tihs ea urreisnuel.t Poef otopole mwuhcoh a urrei ck naociwdn i nto t hhea vbelo tood m. Iut cihs naocitd u innc othmeimr ounri nfoer a ar ed tihaboeseti cw thoo h aarvee o gboeuste ,o hr akvide ndeiya bsetotense as.n d people with gout. livingF irna swseatrtmo earn dcl iKmoahtlesst,a adnt d(2 c0e1r1ta)i nw droieteta, r"yC poantttreirbnust ianngd r miske dfiaccattoiorsn fso".r Ikt iwdnaesy a slstoon setas taerde tohbaet s"iptya,t iiennstusl wini trhe skisidtannecye ,s tgoansetrso sihnoteusltdin ianlc preaathseo lfolugiyd, intake to at least 2 L per 24 hours", (Frassetto and Kohlstadt, 2011). fFrroamss shttttop,: /L/w. &w wK.t,/ aI.f p(2/)./ 1T2r0e1a/tpm1e2n3t4 plrevention of kidney stones:an update. American Family Physician 84(11). Retrieved Rechel DelAntar 5/24/2016 8:28:03 PM Differential Diagnoses Hello Professor and Class, Differential Diagnoses This is a case of a 56 year old female complaining of intermittent severe pain radiating to the flank area extending to the groin accompanied by urgency in urination, nausea and periods of sweating. Further testing shows a Urinalysis result of trace blood, few white cells but no bacteria and an x-ray result, which shows a slightly dilated ureter otherwise, nothing significant. Based on these symptoms the patient may have: 1. Renal Stones = also known as a renal calculus or nephrolith, is a solid piece of material which is formed in the kidneys from minerals in urine. Kidney stones form when your urine contains more crystal-forming substances such as calcium, oxalate and uric acid than the fluid in your urine can dilute. At the same time, your urine may lack substances that prevent crystals from sticking together, creating an ideal environment for kidney stones to form. A stone may stay in the kidney or travel down the urinary tract and they vary in sizes. Small stone may pass on its own, causing little or no pain while larger stone may get stuck along the urinary tract and can block the flow of urine, causing severe pain or bleeding. Other associated symptoms include: nausea, vomiting, fever, blood in the urine, and painful urination. Blockage of the ureter can cause decreased kidney function and dilation of the kidney, which can be seen in an x-ray (Worcester, E., et. al., 2014). This diagnosis fits the symptomatology of the patient and is most likely what the patient is experiencing. 2. Interstitial Cystitis = an inflammation of the bladder. Otherwise known as Painful bladder syndrome, Interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region. The common denominator in interstitial cystitis/painful bladder syndrome is damage to the urothelium, which normally acts as a barrier against insults to the bladder. Damaged urothelium produces cytokines that activate mast cells in the interstitium. The diffusion of excess potassium into the bladder interstitium through a defective urothelium also triggers mast cell activation. The activation of mast cells results in a cycle of neuronal hyperexcitability leading to secretion of neurotransmitters and triggering further mast cell stimulation and degranulation. This process appears to contribute to the chronic pain, urgency, and frequency experienced by patients. People may experience mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area. Symptoms may include an urgent need to urinate, a frequent need to urinate, or a combination of these symptoms. Pain may change in intensity as the bladder fills with urine or as it empties (National Institute of Diabetes and Digestive and kidney Disease, 2013). In PBS/IC, the patient does not exhibit fever and chills or signs of infection however the pain is concentrated more in the abdominal and pubic area. It doe not create ureteral dilatation as seen in the patient’s x-ray eliminating it as a possible diagnosis. 3. Pyelonephritis = Pyelonephritis results when a UTI progresses to involve the upper urinary system (the kidneys and ureters) and is common among females. Symptoms include fever, chills, abdominal pain, nausea and vomiting, painful urination and frequent urination. In this case study however, the patient although experiencing nausea, painful urination and urgency, the patient is not having any fever and chills. The flank pain experienced with pyelonephritis is dull and achy compared to the severe pain experienced by the patient (Imam, T., 2016). Also, pyelonephritis does not use dilation in the ureters as shown in the patient’s x-rays. 4. Urinary Tract Infection = A urinary tract infection (UTI) is an infection in any part of the urinary system; kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract, the bladder and the urethra and occurs mostly in women. Bacteria are the most common cause of UTIs. Normally, bacteria that enter the urinary tract are rapidly removed by the body before they cause symptoms. However, sometimes bacteria overcome the body’s natural defenses and cause infection. Signs and symptoms include a strong, persistent urge to urinate, burning and frequent urination, cloudy urine to blood tinged urine, foul smelling urine and pelvic pain in women from the pelvis to the pubic area. (Lane, D.R. and Takhar, S.S., 2011). The patient although experiencing frequent urination is not experiencing cloudy and foul smelling urine. Also, the type of pain described by the patient does not fit the pain symptoms of a UTI making this diagnosis unlikely. Pain experienced with renal calculi is often described as the strongest sensation ever felt and known as renal colic. It typically comes in waves lasting 20 to 60 minutes caused by peristaltic contractions of the ureter as it attempts to expel the stone. Oral hydration and pain management using NSAIDs are part of the acute treatment of renal calculi. Severe pain is treated by IV pain meds, antispasmodics and opioids to relieve symptoms until other interventions are done to remove renal calculi (Lane D.R. and Takhar, S.S., 2011). References: Imam, T. (2016). Kidney Infection. Retrieved from home/kidney-and-urinary-tract-disorders/urinary-tract-infections-uti/kidney-infection. Lane, D.R. and Takhar, S.S. (2011). Diagnosis and management of urinary tract Infection and pyelonephritis. Emergency Medicine Clinics of North America.29(3). 539-552. National Institute of Diabetes and Digestive and Kidney Disease. (2013). Insterstitial Cystitis/Painful Bladder Syndrome. Retrieved from interstitial-cystitis-painful-bladder-syndrome/Pages/. Worcester, E., Goldfarb, S. and Lam, A. (2014). Cystine Stones. Retrieved from 5/Sarah Boulware reply to Rechel DelAntar 26/2016 11:34:54 AM RE: Differential Diagnoses Rechel, I found your post very informative. During my research I found some information on the treatment of kidney stones. The National Institute of Diabetes and Digestive Kidney Disease (2013) found that if a person is experiencing severe pain from a larger stone shock wave lithotripsy might be needed. The lithotripter machine generates shock waves that pass through the person’s body and break the kidney stone into smaller pieces that can readily pass through the urinary tract. A ureterscope can also be used to perform a Ureteroscopy to enter the bladder up into the urethra and retrieve the stone. These are more extreme treatments. Like you mentioned in your post pain medication and fluids are often used. If possible the patient should drink a lot of fluid to help move the stone along the ureter and out of the body. If the patient is dehydrated from vomiting and nausea IV fluids will be necessary. Many patients don’t seek treatment until they are having pain caused by the stone. At this point they are in a lot of pain requiring medication and fluid. Reference The National Institute of Diabetes and Digestive and Kidney Diseases. (2013). Kidney stones in adults. Retrieved from kidney-stones-in-adults/Pages/#treated Rechel DelAntar reply to Sarah Boulware 5/26/2016 6:58:50 PM RE: Differential Diagnoses Hello Sarah, Im glad you find my post informative. You are right, lithotripsy is used as non-invasive way of removing stones that are too big to pass and at this point is pressing on the renal calyx causing pain. Most renal stones that are too big remain on calyx since they are unable to pass to the ureters. These stones are so big they cause hydronephrosis and getting them out becomes urgent. Treatment for renal calculi starts with pain medications until the size of the calculi is determined via ultrasound or x-ray. Once it is determined it is too big to pass then a lithotripsy will then be performed to break up the larger stones to smaller one allowing the patient to pass it through the urinary tract. Patient's are encouraged to strain urine in order to determine if they have passed the stones (Cecen, K. ., 2014). And you are right, increase in fluid intake is necessary to flush out the calculi. If this is not effective then more invasive means have to be done to extract the renal calculi. Reference: Cecen, K., Karadag, M., Demir, A., Bagcioglu, M., Kocaasia, R. and Sofikerim, M. (2014). Flexible Ureteroscopy versus Extracorporeal Shockwave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10-20mm: a retrospective analysis of 174 patients. Retrieved from Deborah Matheny reply to Sarah Boulware 5/29/2016 5:56:29 PM RE: Differential Diagnoses Hello Sarah and Rechel: I found both of your posts informative and I can add to the conversation through personal experience. In 1994 I had my first encounter with kidney stones and I can confirm that the pain is excruciating especially when a blockage has occurred. I had a complete blockage and had to have a stent placed and removal with what they had called a basket then I had lithotripsy to break up remaining stones for ease of passage. Lithotripsy is when they use shock waves to break up the stones (crush them almost into a sandy material) and afterwards I can tell you that you feel as if you had been hit by a truck as you ache for several days afterwards. Several years later I had a recurrence of stones but no stent was needed at this time but lithotripsy was still called for as several stones were too large to pass on their own and a third and final experience occurred in 2000 where blockage again occurred, a stent was placed and lithotripsy was also used. In two cases the stones were calcium oxalate while the third and final time the stones were calcium phosphate. I can honestly say that it took three episodes for me to finally believe that drinking more fluids (not soda and coffee) was needed to prevent any further episodes (I admit to being hard-headed at times). My urologist encouraged me to drink one 6-oz glass of cranberry juice daily as this would help flush any sediment out of my kidneys before any stones formed again. I have not had another episode since 2000, I drink 4 to 6 bottles of water daily, and I still drink that one glass of cranberry juice daily. Whether it works or not I believe it does and will continue to drink it. I will admit that all three experiences were very painful with the stones and with the lithotripsy. As a RN I have discussed my experience with several urologists and have found that those that have been in practice for a longer period recommend use of cranberry juice while those who have less time in this field encourage more fluid intake but are on the fence about whether cranberry juice works or not. If I am asked I tell about my experience only but as a nurse practitioner I believe I will encourage drinking cranberry juice to help in preventing reoccurrence. Again let me thank you both for an informative and interesting read. Debbie 5/Jonathan Bidey reply to Rechel DelAntar 29/2016 10:23:38 AM RE: Differential Diagnoses Rachel, eExxpceerlileennct ipnogs kt!i d Yneoyu sdtiodn ae sw. oYnodue rmfuel njtoibo ndeeds cpraibinin mg atnhaeg deimffeenretn utniatli ld tihaeg nstoosnees ifso