Chronic Health Problem Management Flashcards
(51 cards)
What is multimorbidity vs comorbidity?
Cooccurence of two or more chroncic medical conditions that are not necessarily related to each other (HTN and depression)
Comorbidity = conditions that coexist and relate to each other (DM and HTN)
What is a downfall of geriatrics?
Lack of evidence based medicine
Complicated treatment regimens
Intensified communication (set a goal, explain risks/benefits)
Financial compensation
What patient might moderate/intense exercise be CI?
Osteoporosis patient
What are the steps that determine care of geriatric patient?
1.Determine prognosis
2. Elicit patient preference
3. Assess treatment plan (START AND STOPP screening tools)
What to do if patient has >10 years life expecnacy
2-10 years
<1-2 years
> 10 years life expectancy with few chronic conditions & few to no functional limitations = follow disease-specific guidelines & patient preferences
2 to 10 years life expectancy with increasing number of severity of chronic conditions and functional impairment
= follow the multiple chronic condition actions steps
<1 to 2 years life expectancy with advanced illness
= guideline-specific care to aggressively treat and manage disease is often NOT best aligned with patient goals and preferences
= focus on aggressive palliative care
= prioritize quality of life over quantity of life
What is urinary inconctinence? Demographics?
Involuntary loss of urine in geriatric patients (aka as geriatric syndrome)
15%-30% of healthy adults
More common in women
Aging does not cause it
Caused by decline in bladder capacity
Increase in residual urine
Increase in involuntary bladder contractions
Related to diminished estrogen influence & laxity of pelvic floor structures
Associated with childbirths, surgeries, and deconditioned muscles
What are the 4 urine inconctinence types?
Overflow
Stress
Urge
Functional
What are the risk factors of urinary incontinence?
Increasing age
Female gender
Multiparity
Cognitive impairment
Genitourinary surgery
Obesity
Impaired mobility
Prostate enlargement
Bladder prolapse
Urethral strictures
Bladder stones
Estrogen-deficient tissue atrophy
What causes Overflow incontinence and what are some of the causes?
Loss of urine in the setting of excessive bladder volume as a result of impaired bladder wall contraction or urinary sphincter relaxation
Signs/symptoms:
Dribbling, weak urinary stream, intermittent or continuous leakage, hesitancy, frequency, nocturia, high post-void urinary volume
Potential causes:
Benign prostatic hyperplasia (BPH), prostate cancer, urethral stricture, GU organ prolapse, anticholinergic medication, neuropathy, spinal cord injury, detrusor underactivity [impaired urothelial sensory function, fibrosis, low estrogen, Continued…peripheral neuropathy (DM, Vit B12 def, ETOH), spinal cord detrusor efferent nerve damage (MS, spinal stenosis)], bladder outlet obstruction (fibroids, organ prolapse), tumors, urethral stricture, uterine incarceration from a retroverted uterus
What is stress inconctinence and what are the s/s
Loss of urine when abrupt increase in intra-abdominal pressure exceeds urethral sphincter closing pressure
Signs/symptoms:
Often small volumes, associated with activities such as cough, laugh, sneeze, standing, or bending
Potential causes:
Genitourinary (GU) atrophy or prolapse, urethral sphincter trauma, pelvic floor weakness
(caused by coughing, laughing ect)
What causes urge inconctinence (overactive bladder)
Loss of urine caused by uninhibited detrusor muscle activity at inappropriately low urinary volumes
What should you check on PE of urinary incontinence?
- CV Exam: look for evidence of CHF & excessive peripheral edema
- Abdominal Exam: assess for a palpable bladder, pain & masses
- GU Exam: DRE → enlarged or tender prostate (suggests BPH or infx)
→ rectal or prostate masses (suggest carcinoma)
→ fecal impaction (remove to see if urinary flow improves)
→ rectal tone & perineal sensation- Peripheral Motor and Sensory Exam (spinal cord & neuropathic conditions)
- Genitalia Exam in males:
→ Penis (phimosis, drainage, lesions)- Pelvic exam in females:
→ Organ prolapse
→ Excessive GU tissue atrophy
→ A bimanual examination (uterine or pelvic masses)
- Pelvic exam in females:
What imaging studies can you do for UI?
KUB
Renal ultrasound
CT scan
Mnemonic for reversible UI
DRIP
delirium
restricted mobility/retention
infection, inflammation
polyuria, pharm cause
What are some behavorial modifications for UI?
Toileting after meals, prior to bedtime, or before vigorous physical exercise if these events are regularly associated with incontinence
Scheduled voiding (every 2 hrs) & prompted voiding
Frequent inquiry about the need to pass urine & assistance to the toilet when the response is “yes.”(used by caregivers of cognitively impaired adults with functional or urge incontinence)
Pelvic muscle training (Kegel exercises)
Lifestyle modification (wt loss, fluid restriction, reduce caffeine, stop smoking)
Depends or pads
Wicking devices for skin protection
If a patient has UI, what specilaist do you contact?
Neurology
Urology
First line therapy for stress, urge,
Stress: 6-12 weeks conservative therapy trial (behavioral, lifestyle, kegal exercises, topical vaginal estrogen therapy if peri- or post-menopausal)
Urge: conservative treatment (exercise, lifestyle, behavior)
When do you refer for urinary incontinence?
Sudden onset with associated abdominal/pelvic pain
Gross or microscopic hematuria in the absence of a UTI
Culture-documented recurrent UTI
New neurologic symptoms
Suspected urinary fistula or urethral diverticulum
Chronic catheterization
Difficulty passing a urinary catheter
Pelvic organ prolapse beyond the hymen
History of pelvic reconstructive surgery or pelvic radiation
Urinary retention
Persistent elevated postvoid residual
What defines constipation>
Hard or lumpy stool
Straining
Sensation of incomplete evacuation
Sensation of anorectal obstruction or blockage
Manual maneuvers to facilitate ≥25% of defecations (eg, digital evacuation, support of the pelvic floor)
Fewer than 3 defecations per week
What can cause fecal incontinence?
Disruption of the stooling process can cause fecal incontinence
Constipation
Problems with laxative use
Neurological disorders
Colorectal disorders
Constipation, when chronic, leads to fecal impaction and incontinence
The hard stool of the impaction irritates the rectum
Results in production of mucus and fluid
Fluid leaks around the mass of impacted stool and precipitates incontinence
What are the symptoms of fecal incontinence?
Bloating
Fullness
Incomplete evacuation
What are some alarm symptoms of fecal incontinence? What do you do if these are positive
Hematochezia
Family history of colon cancer/inflammatory bowel disease
Anemia
Positive fecal occult blood test
Unexplained weight loss ≥10 pounds
Constipation that is refractory to treatment
New-onset constipation without evidence of potential primary cause
If + alarm symptoms, may necessitate further evaluation with more invasive testing
Older patients should consider the benefits and risks of doing further evaluation with colonoscopy or other invasive testing
How should you void if having trouble?
Kness higher than hips
Lean forward with elbows on knees
Bulge abdomen
Straighten your spine
What labs and imaging do you get for fecal incontinence?
CBC
Thyroid function tests
Fecal occult blood testing
Abdominal plain films
May detect significant stool retention in the colon and suggest the diagnosis of megacolon
