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**Urinary Tract Infection (UTI)
- Most common bacterial infection in women
- At least 20% of women will develop a UTI during their lifetime
- Bladder and its contents are free of bacteria in majority of healthy persons (it's a sterile environment! so is foley procedure, although at home it's clean because it's their own germs)
Minority of healthy individuals have colonizing bacteria in bladder; Called asymptomatic bacteriuria and does not justify treatment ( Asymptomatic bacteriuria does not justify screening or treatment except in pregnant women.) Is the patient symptomatic? Then it doesn't require treatment. But in majority of people, bladder is sterile
Escherichia coli most common pathogen because it lives in the rectum!
- Counts of 105 CFU/mL or more indicate significant UTI
- Counts as low as 102 CFU/mL in a person with signs/symptoms are indicative of UTI
Fungal and parasitic infections can cause UTIs also, but less common that bacteria.
- => Patients at risk
- Immunosuppressed: by meds (corticosteroids, HIV, chemo pts)
- Having undergone multiple antibiotic courses
- Have traveled to developing countries
- *note: At least 20% of women develop a UTI during their lifetime.
- More than 100,000 people are hospitalized annually for UTIs.
- More than 15% of patients who develop gram-negative bacteremia die, and one third of these cases are caused by bacterial infections originating in the urinary tract.
**Classification of UTI: Upper vs Lower
- => Upper urinary tract
- Renal parenchyma, pelvis, and uretersTypically causes fever, chills, flank pain
- Example : Pyelonephritis: inflammation of renal parenchyma and collecting system (the infection is actually in the kidneys)
- Upper has more complications, and has different treatments!
- S/S: fever, chills, and flank pain (usually on the side of the kidney that is involved)
- => Lower Urinary Tract
- Usually no systemic manifestations
- involves bladder or ureters
- Examples: Cystitis: inflammation of bladder & Urethritis: inflammation of the urethra
- s/s: low grade or no fever
**Classification of UTI Complicated versus uncomplicated
- => Uncomplicated UTI
- Occurs in otherwise normal urinary tract
- Usually involves only the bladder
- => Complicated UTI
- Coexists with presence of other conditions: Obstruction
- Diabetes/neurologic disease
- Pregnancy-induced changes
- Recurrent infection
Treatments differ with complicated vs. uncomplicated
The individual with a complicated infection is at risk for pyelonephritis, urosepsis, and renal damage.
**UTI Etiology and Pathophysiology
=> Urinary tract above urethra normally sterile due to many defense mechanisms
- => Defense mechanisms exist to maintain sterility/prevent UTIs: Complete emptying of bladder
- Ureterovesical junction competence
- Peristaltic activity
- Acidic pH (so alkaline environment is a risk factor)
- sphincter that prevents backflow of theurine from bladder into the ureters and kidneys (which would cause recurrent upper UTIs)
=> Alteration of defense mechanisms increases risk of contracting UTI
- => Predisposing factors
- Factors increasing urinary stasis; Examples: BPH, tumor, neurogenic bladder (when pt can't empty bladder on their own due to stroke, or spinal cord injuries.)
- Foreign bodies; Examples: catheters, calculi, instrumentation (A common factor contribuin to ascending infection is urological instrumentaion which allows bacteria that are normaly present at the opening o the urethra to enter into the rethra or bladder)
- Anatomic factors; Examples: obesity, congenital defects, fistula
- Compromising immune response factors:Examples: age (elderly women especially), HIV, diabetes
- Functional disorders; Example: constipation
- Other factors: Examples: pregnancy, multiple sex partners (women)
- Majority of the time: Organisms introduced via the ascending route from urethra and originate in the perineum and Less common routes: Bloodstream, Lymphatic system
- Gram-negative bacilli normally found in GI tract: common cause
- Urologic instrumentation allows bacteria to enter urethra and bladder
- Huge Contributing factor: urologic instrumentation (like straight or foley cath left in); Allows bacteria present in opening of urethra to enter urethra or bladder
- Sexual intercourse promotes “milking” of bacteria from perineum and vagina; May cause minor urethral trauma (so urinate after intercourse)
- **Hospital-acquired UTI accounts for 31% of all nosocomial infections because then it's the hospital responsibility.-other nonscomonial: pneumonia, ventiallated associated pneumonia, C. Diff, VRE
- Causes: Often: E. coli, Seldom: Pseudomonas speciesCatheter-acquired UTIs: Bacteria biofilms develop on inner surface of catheter (CAUTI); hosptials are supposed to report it and insurance aren't paying for it; they are the most common HAI's
**Clinical Manifestations of UTIs
Upper vs lower?
- Symptoms related to either bladder storage or bladder emptying
- Urinary frequency
Flank pain, chills, and high fever indicate infection of upper tract (Pyelonephritis)
urinary freq, urgency, hesitancy, dysuria, and low grade fever< Nocturia, Noctural enuresisPyelonephritis: flank plain along with lower uti s/s
*note: Lower urinary tract symptoms (LUTS) are experienced in patients who have UTIs of the upper urinary tracts, as well as those confined to the lower tract.
- The urine may contain grossly visible blood (hematuria) or sediment, which gives it a cloudy appearance.
- Symptoms are related to either bladder storage or bladder emptying. These symptoms are defined in Table 46-3. People with significant bacteriuria may have no symptoms or may have nonspecific symptoms such as fatigue or anorexia.
- => In older adults
- Symptoms often absent like fever, come in with vague/nonnlocalized symptomsNonlocalized abdominal discomfort rather than dysuriaCognitive impairment possible (so now ask about baseline!)Fever less likelyImmediately rule out pneumonia and a UTI Because older adults are less likely to experience a fever with a UTI, the value of body temperature as an indicator of a UTI is unreliable.
**UTI Diagnostic Studies
In a patient suspected of having a UTI, initially conduct dipstick urinalysis to identify the presence of nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs that indicates pyuria). These findings can be confirmed by microscopic urinalysis.
History and physical examination
Dipstick urinalysis : Identify presence of nitrites, WBCs, and leukocyte esterase (not done at bedside anymore
- => Urine for culture and sensitivity (if indicated)
- Clean-catch sample preferred or else sample will be contaminated--a voided mistream techniqque; Refrigerate urine immediately, and culturedd within 24 hours
- Specimen by catheterization more accurate because sterile is best.
- Sensitivity: Determine bacteria susceptibility to antibiotics but meannwhile, we start treating the patient.
- *note: A urine culture is indicated in complicated or HAI UTIs, persistent bacteriuria, or frequently recurring UTIs (more than two to three episodes per year). Urine also may be cultured when the infection is unresponsive to empiric therapy or the diagnosis is questionable.
- For women, teach them to spread the labia and wipe the periurethral area from front to back, using a moistened, clean gauze sponge (no antiseptic is used because it could contaminate the specimen and cause false-positive results). Then tell them to keep the labia spread and collect the specimen 1 to 2 seconds after voiding starts.
- For men, instruct them to wipe the glans penis around the urethra. The specimen is collected 1 to 2 seconds after voiding begins.
- ==> UTI Imaging studies
- CT urography or ultrasonography when obstruction suspected
- especially when we suspect obstruction (tumor or stones),
UTI Drug Therapies:
2. Ampicillin, Amoxicillin, Cephalosporins
6. Urinary Analgesic. Name?
- 1. Trimethoprim/sulfamethoxazole (TMP/SMX)
- Used to treat uncomplicated or initial UTI
- Taken twice a day
- E. coli resistance to TMP-SMX ↑
; Given three or four times a day (more difficult to keep up for a pt)Long-acting preparation (Macrobid) is taken twice daily
- **Ampicillin, amoxicillin, cephalosporins
- Treat uncomplicated UTI
- Treat complicated UTIs
- Example: ciprofloxacin (Cipro)
- Amphotericin or fluconazole
- UTIs secondary to fungi
- Phenazopyridine (Pyridium)-short term use, but in combination with antibiotics!
- Used in combination with antibiotics
- Provides soothing effect on urinary tract mucosa
- Stains urine reddish orange ; Can be mistaken for blood and may stain underclothing Although this drug is typically effective in relieving the transient acute discomfort associated with a UTI, the nurse should advise patients to avoid long-term use of phenazopyridine because it can produce hemolytic anemia.
-Individuals at risk
-Ambulatory and home care
- =>Recognize individuals at risk
- Debilitated persons
- Older adults (poor hygiene, caregiver education?)
- Underlying diseases (HIV, diabetes)
- Taking immunosuppressive drug or corticosteroids
- => Health Promotions:
- Emptying bladder regularly and completely
- Evacuating bowel regularly
- Wiping perineal area front to back
- Drinking adequate fluids (older ppeople not wanting to use diapers, so they cut down on fluids)
- Cranberry juice or cranberry tablets may reduce the number of UTIs ( It is thought that enzymes found in cranberries inhibit attachment of urinary pathogens (especially E. coli) to the bladder epithelium. )
- Avoid unnecessary catheterization and early removal of indwelling catheters
- Aseptic technique must be followed during instrumentation procedures
- Wash hands before and after contact
- Wear gloves for care of urinary system
- Routine and thorough perineal care for all hospitalized patients
- Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
- => Acute intervention
- Adequate fluid intake (Flush out bacteria before they have a chance to colonize in the bladder, dilute urine also makes it less irritable
- Patient may think condition will worsen because of discomfort
- Dilutes urine, making bladder less irritable
- Flushes out bacteria before they can colonize
- Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods (bladder irritants!) Application of local heat
- Emphasize taking full course of antibiotics despite disappearance of symptoms
- => Ambulatory and home care
- Emphasize importance of compliance with drug regimen; Take as ordered
- Maintain adequate fluidsRegular voiding (every 3 to 4 hours)Void after intercourse
- Inflammation of renal parenchyma and collecting system
- Most commonly caused by bacteria
- Fungi, protozoa, or viruses can also infect kidneys
- -Acute: usually starts in the renal medulla nad spreads to the adjacent cortex (risk: pregnancy induced physiolgic changes in urnary system)
- -Urosepsis is characterized by bacteriuria and bacteremia (bacteria in blood)
- => Urosepsis: Systemic infection from urologic source (so therapy is different and time is of essence!)
- Prompt diagnosis/treatment critical
- Can lead to septic shock and death
- Septic shock: outcome of unresolved bacteremia involving gram-negative organism
- Get urine and blood cultured!
Pyelonephritis: Etiology, Patho & Manifestations!
- **Etiology and Pathophysiology
- Usually begins with colonization and infection of lower tract via ascending urethral route
- => Frequent causes
- Escherichia coliProteusKlebsiellaEnterobacter
- => Preexisting factor usually present-Vesicoureteral reflux: Backward movement of urine from lower to upper urinary tract
- -Dysfunction of lower urinary tract: Obstruction from BPH (benign prostatic hyperplasia)
- Urinary stone-For residents of LTC, urinary tract cath is a common cause of pyelonephritis and urosepsis.
Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis which can become end-stage kidney disease!
- **Clinical Manifestations
- Mild fatigueChillsFeverVomitingMalaiseFlank pain
- Lower urinary tract symptoms characteristic of cystitis
- Costovertebral tenderness usually present on affected side
- Manifestations usually subside in a few days, even without therapy; Bacteriuria and pyuria still persist
-Urinalysis shows: pyuria, bacteriuria, and varying degrees o hematuria. WBC casts may be found in the urine, indicateing involvement of the renal perenchyma. A complete blood count shows leukocytosis and a shift to the left with an increase in bands (immature neutrophils)
Pyelonephritis Diagnositcs & Drug Therapy
History Physical examination: CVA pain
- => Laboratory tests
- Urine for culture and sensitivity
- CBC with differential
- Blood culture
- CT urography
- If bacteremia is a possibility, close observation and vital sign monitoring are essential
- Prompt recognition and treatment of septic shock may prevent irreversible damage or death
- **Collaborative Care
- Hospitalization for patients with severe infections and complications; Such as nausea and vomiting with dehydration
Signs/symptoms typically improve within 48 to 72 hours after therapy starts
- **Drug therapy:
- =>Antibiotics: Parenteral administration in hospital to rapidly establish high drug levels
- => NSAIDs or antipyretic drugs
- => Urinary analgesics
**ACUTE vs CHRONIC Pyelonephritis:
- In chronic, the kidneys become small, atrophic and shrunken and lose function due to fibrosis (scarring)
- -the result of recurring infection involing the Upper urinary tract
- confirmed by radiological imagining and a biopsy (indicate loss of functioning nephrons, infiltration of the parenchyma with inflammatory cells and fibrosis); imaging shows small, fibrotic kideys with hydronephrotic collecting system.
-Chronic pyelo often progresses to end stage kidney (renal) disease (ESKD) even if the underlying infection is successfully treated.
Glomerulonephritis & APSGN
•Glomerulonephritis, inflammation of the glomeruli, results from an antibody-induced injury. It is described in a number of ways: extent of damage (diffuse or local), cause, or extent of changes (minimal or widespread). -Third leading cause of ESKD
of glomerulonephritis include varying degrees of hematuria and urinary excretion of various formed elements, including red blood cells (RBCs), white blood cells (WBCs), proteins, and casts
-Chronic: slowly progressive, generally leading to irreversible renal fiaulture.
- **Acute Poststreptococcal Glomerulonephritis
- • Acute poststreptococcal glomerulonephritis (APSGN) develops 5 to 21 days after an infection of the tonsils, pharynx, or skin by nephrotoxic strains of group A beta-hemolytic streptococci. most common in children and younger adults.
- • Manifestations include generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria.
- -Fluid retention due to decreeased Glom filtration, inital edema in low pressure tissues(around eeyes) but eventually total body ascites or peripheral.
- -SMoky urine: leading in the upper urinary tract-Diagnosed on routie urinalysis; immune response test by ASO (Antistreptolysin O) Titers
- •APSGN management focuses on symptomatic relief. This includes rest, edema and hypertension management, and dietary protein restriction when an increase in nitrogenous wastes (e.g., elevated blood urea nitrogen [BUN] value) is present.
- -Limit sodium and fluid intake, diuretics for the edema
- •One of the most important ways to prevent the development of APSGN is to encourage early diagnosis and treatment of sore throats and skin lesions.
• Chronic glomerulonephritis is a syndrome that reflects the end stage of glomerular inflammatory disease.
• It is characterized by proteinuria, hematuria, and the slow development of uremia (urea in blood). Treatment is supportive and symptomatic.-develops slowly over time, usually found with elevated BP and abnormal urinalysis
-Clinical manifestiations: hematuria, urinary excretion of formed elements (RBCS, WBCs, casts), proteinuria, elevated BUN and creatiine levels
-Manifestations & Treatment
Nephrotic syndrome results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin (because you're peeing it out) and tissue edema (loss of serum protein). It is often associated with systemic illness, such as diabetes or lupus.
- => Manifestations : peripheral edema with ascites and anasarca (massive genralized edema due to severe hypalbuminemia), hypertension, proteinuria, hypoalbuminemia, and hyperlipidemia. Hypercoagulability is common (because you have a urinary loss of anticoagulant proteins so thromboembolism is a huge risk!)
- --> dimnished plasma oncotic pressure from the decrease serum proteins stimulates hepatic lipoptoein synthesis which results in HYPERlipidemia and eventually fat bodies show up in urine
- Infection is the primary cause of morbidity (immune responses-both humoral and cellular, are latered in nephotic syndrome)
- -Patients are usually anorexic and malnoursished (small frequent meals are good)
- •Treatment is focused on symptom management. The major nursing interventions are related to accurately assessing and managing edema.
- -Edema: cautious use of ACE inhibors, NSAIDS, and a low soddium (2-3 g/day), moderate protein diet
- -Lipid lowering agents: statins, colestipol-teach pt to avoid exposure to infecteed people.
**Urinary Tract Calculi or "Nephrolithiasis"
•Factors involved in the development of urinary tract calculi include metabolic, dietary, genetic, climatic, lifestyle, and occupational influences. Other factors are obstruction with urinary stasis and urinary tract infection.
- •The five major categories of stones (lithiasis) are (1) calcium phosphate, (2) calcium oxalate, (3) uric acid, (4) cystine, and (5) struvite.
- -If urine is too alkaline: calcium and phosphate are less soluble
- -Acidic environment: uric and cystine are less soluble
- -Struvite more llikely to form in alkaline uine due to urea splitting bacteria (proteus, klebsiella, psudomonas)
•Urinary stones cause clinical manifestations when they obstruct urinary flow. Common sites of complete obstruction are at the ureteropelvic junction (UPJ), the point where the ureter crosses the iliac vessels, and at the ureterovesical junction.
severe abdominal or flank pain, hematuria, and renal colic. A common symptom of renal colic (the pain that results from stretchig, dilation, and spasm of the ureter in response to the obstructing stone. N/V may occur also) is that patients cannot remain still. They sit, then stand, then lie down and then repeat the process "kidney Stone Dance".
- => diagnostic:
- CT/KUB for renal colic
- -complete urinalysis helps confirm diagnosis of stone: assess for hematuria, crystalluria, and urinary pH
• Management of a patient with renal lithiasis consists of treating the symptoms of pain, infection, or obstruction.
• Lithotripsy is the use of high-energy shock waves to fragment and disintegrate kidney stones. It is used to eliminate calculi from the urinary tract. Outcome for lithotripsy is based on stone size, stone location, and stone composition.
• The goals are that the patient with urinary tract calculi will have relief of pain, no urinary, tract obstruction, and an understanding of measures to prevent further recurrence of stones
.• To prevent stone recurrence the patient should consume an adequate fluid intake to produce a urine output of approximately 2 L/day. Additional preventive measures focus on lifestyle and dietary changes or medications, depending on the type of stone involved.
**Risk factors for urinary Tract Calculi:
-Metabolic: abnormalities that result in increased urine levels of calciu, oxaluric acid, uric acid, or citric acid.
-Climate: warm climates that cause increase fluid loss, low urine volume and increased solute concentration in urine
- -Diet: large intake of diettary protein increases uric acid excretion
- -excessive amounts of tea/fruit juices elevate urinary oxalate-large intake of calciu and oxalate
-Genetics: family history, lifestyle, sedentary occupation, immobility.
**HEREDITARY RENAL DISEASES=> Polycystic Kidney Disease
•Polycystic kidney disease (PKD) is a common life-threatening genetic disease, characterized by cysts that enlarge and destroy surrounding tissue by compression. Fifty percent of patients have end-stage renal disease by age 60.
- -Two kinds:
- childhood form: rare autosomal recessve disorder
- adult PDK: latent for many years, but manifests at age 30-40 (autosomal dominant)
UTI, urinary calculi, cronic paid-affects liver: liver cysts, heart (abnormal heart valves) blood vessels (aneurysms) and intestines (divertiulosis)
• Diagnosis is based on clinical manifestations, family history, IVP, ultrasound, or CT scan.
• There is no specific treatment for PKD. The measures used are the same as those used for the management of end-stage kidney disease.
- • Renal cell carcinoma (adenocarcinoma) is the most common type of kidney cancer.
- • Cigarette smoking is the most significant risk factor for renal cell carcinoma.
- • Since there are no early symptoms of kidney cancer, many patients go undiagnosed until the disease is advanced. About 30% of patients have metastasis at the time of diagnosis.
- • Common presenting manifestations are hematuria, flank pain, and a palpable mass in the flank or abdomen.
- • The treatment of choice for kidney cancer is a partial or total nephrectomy and lymph node dissection as indicated for patients with stage I or II tumors and selected stage III tumors.
- o Other treatment options include cryoablation and radiofrequency ablation.o Chemotherapy is used as a treatment in metastatic disease, but the tumors are frequently refractory to most chemotherapy drugs.
- o Biologic and targeted therapy are used to treat metastatic kidney cancer and includes sunitinib (Sutent), sorafenib (Nexavar), temsirolimus (Torisel), everolimus (Afinitor), ofatumumab (Arzerra), bevacizumab (Avastin), and pazopanib (Votrient).
• Risk factors for bladder cancer include cigarette smoking, exposure to dyes used in the rubber and cable industries, chronic abuse of phenacetin-containing analgesics, and chronic, recurrent renal calculi.
• Microscopic or gross, painless hematuria (chronic or intermittent) is the most common clinical finding with bladder cancer.
• Surgical therapies for bladder cancer include transurethral resection with fulguration, laser photocoagulation, and open loop resection.
• Postoperative management includes instructions to drink a large volume of fluid each day for the first week following the procedure and to avoid intake of alcoholic beverages.
• Chemotherapy or immune-stimulating agents can be delivered directly into the bladder by a urethral catheter. Bacille Calmette-Guérin (BCG) is the treatment of choice for carcinoma in situ.
BENIGN PROSTATIC HYPERTROPHY(HYPERPLASIA)
- A. Description
- 1. Benign prostatic hypertrophy (benign prostatichyperplasia; BPH) is a slow enlargement of theprostate gland, with hypertrophy and hyperplasiaof normal tissue.
- 2. Enlargement compresses the urethra, resultingin partial or complete obstruction.
- 3. Usually occurs in men older than 50 years
- B. Assessment
- 1. Diminished size and force of urinary stream(early sign of BPH)
- 2. Urinary urgency and frequency
- 3. Nocturia
- 4. Inability to start (hesitancy) or continue a urinarystream
- 5. Feelings of incomplete bladder emptying
- 6. Postvoid dribbling from overflow incontinence(later sign)
- 7. Urinary retention and bladder distention
- 8. Hematuria
- 9. Urinary stasis
- 10. Dysuria and bladder pain
- 11. UTIs
- renal studies
- Transrectal ultrasound
BPH Etiology, Risk Factors and Complications
- **Etiology and Risk Factors
- Hyperplasia occurs from age- related endocrine changes
- Enlargement of prostate compresses urethra
- Risk factors include family history, diet, obesity
- Symptoms either obstructive or irritative
- =>Potential Complications
- Urinary tract infections
- Urinary calculi
- Urinary incontinence
- Acute urinary retention
- Hydronephrosis or post-renal failure
1. Encourage fluid intake of up to 2000 to 3000mL/day unless contraindicated.
2. Prepare for urinary catheterization to drain thebladder and prevent distention.
3. Avoid administering medications that causeurinary retention, such as anticholinergics, antihistamines,decongestants, and antidepressants.
4. Administer medications as prescribed toshrink the prostate gland and improve urineflow.
5. Administer medications as prescribed to relaxprostatic smooth muscle and improve urine flow.
6. Instruct the client to decrease intake of caffeineand artificial sweeteners and limit spicy or acidicfoods.
7. Instruct the client to follow a timed voiding schedule.
8. Prepare the client for surgery or invasive proceduresas prescribed (Box 62-17; Figs. 62-7 and62-8).
Alpha adrenergic receptor blockers: Flomax
5 alpha reductase inhibitors: Proscar
BPH Surgical interventions and postoperative care
- => Minimally Invasive Therapies
- Intraprostatic uretheral stents
- Prostatic balloon dilation
- Microwave therapy (TUMT)
- Transurethral needle ablation (TUNA
- Laser ablation (TULIP, VLAP)
- => Surgical Intervention
- TURP- surgery of choice for moderate prostatic enlargement
- TUIP- small prostate < 30g
- Open prostatectomy - large prostate > 60g
- Suprapubic - surgery of choice
- Retropubic - commonly done for CA Perineal - rarely done
=>Transurethral microwave thermotherapy: Application of heatto destroy the hypertrophied tissue.
=>Transurethral needle ablation of the prostate (TUNA):
Placement of interstitial radiofrequency needlesthrough the urethra and into the lateral lobes of theprostate, causing heat-induced coagulation necrosi sof the prostate for treating benign prostatic hypertrophy(BPH).
=>Transurethral resection of the prostate (TURP):
=> Post Op:
Removal ofbenign prostatic tissue surrounding the urethra withuse of a resectoscope introduced through the urethra;there is little risk of impotence and it is most commonlyused for BPH.
- => Preop:
- Preoperative CareUrethral catheter (coudé)AntibioticsIncrease fluid intake (2-3L/day)Inform patient/family what to expect before, during, & after surgery to reduce anxiety
- => Postoperative Care
- Continuous bladder irrigation with normal saline for 24 hrs or until no clots
- Minimize activities that increase intraabdominal pressure
- Control bladder spasms
- => Discharge Planning
- Discontinue catheter 2-4 days after surgery Kegel exercises 10-20X WA
- Teach/observe for signs of infection
- Avoid alcohol & caffeine
- Consume high fiber diet
- Fluid intake 2-3L/day
- Avoid lifting > 10 lbs
- No driving or sexual intercourse for 6 wks or as specified by surgeon
Takes 3-6 months to take an effect on treatment of BPH. Cannot be handled by pregnant.
Assess bowel sounds before adminstering
Used for BPH treatment, takes 2-3 weeks to take an effect, main SE orthostatic hypotension
Any medication that contains this electrolyte must be avoided in patients with ESRD
Taken with meals to reduce certain electrolyte absorption in patients with ESRD