NR 601 FINAL STUDY GUIDE 2024
Review Ham 7th Edition
Review Module lessons & interactive activities
Exam Preparation Create your personal study guide, flash cards, etc as you read & review the course content
based on your preferred study methods to prepare for the exam.
Read the course lessons provided in the Modules and participate in the interactive activities.
The lessons were created specifically for the 601 course by a team of experts, to provide
interactive, engaging methods to learn and expand knowledge.
Schedule blocks of time each week to study. Add those dates/times to your calendar to stay
organized.
Week 5 Genitourinary Disorders
Urinary incontinence
o Distressing, impacts older adults’ quality of life and socialization.
o Increases risk of skin breakdown and falls.
o Leading reason for placement in long-term care.
o 20% women with incontinence in community and 75% women with
incontinence in LTC.
o Men younger than 85 have lower incidence, but older than 85 is the same as
women.
o Urinary incontinence: Involuntary urine leakage.
o Urgency: Sudden need to void.
o Urgency incontinence: Sudden need to void followed by leakage.
o Frequency: Frequent urination.
o Hesitancy: Difficulty in initiating a urine stream.
o Straining: Effort to initiate or maintain a urine stream.
o Dribbling: Leaking of small amounts of urine after voiding.
o Nocturia: Waking during the night to void.
o Overactive bladder: urgency, frequency, and nocturia
o Risk factors: requiring assistance to ambulate, hysterectomy, female gender,
obesity, using a walker, diabetes, depression, advanced age, neurologic
impairment, past CVA, cognitive impairment, fecal incontinence.
o Assessment: detailed history of onset, duration, and severity of symptoms,
including presence of nocturia and sleep disruption and impact on quality of
life.
o Stress incontinence: Leakage with exertion or coughing, sneezing, or laughing.
o Mixed incontinence: urgency and stress incontinence symptoms.
o Treatment:
Treat comorbidity: sleep apnea, diabetes. They must be managed
before implementing other treatments for urinary incontinence. Review
current medications.
Lifestyle interventions: weight loss, reducing consumption of caffeine
and alcohol, decreasing fluid intake before bed, smoking cessation.
Behavioral therapies: bladder training, pelvic muscle exercises (Kegels).
Useful for stress and urgency incontinence. Prompted voiding.
Bladder training: frequent voiding every two hours along with
visualization and muscle contractions to help control urgency.
As training progresses, time between voiding is increased. May
, take several weeks.
Pelvic muscle exercises (Kegels): help to strengthen pelvic floor.
Exercises may be done throughout the day, with a goal of 10-12
per day. May begin to improve incontinence in a month.
Prompted voiding: May decrease incontinence episodes in
cognitively impaired clients. Caregiver should prompt the
patient to void and assist in toileting every 2-3 hours.
Medications: Not approved for stress incontinence. May be used for
urgency incontinence or overactive bladder.
Antimuscarinic medications: Oxybutynin (Ditropan), tolterodine
(Detrol): monitor for anticholinergic adverse effects, drugs
interact with drugs that induce CYP2D6, avoid in clients with
dementia or cognitive impairment (BEERS)
Beta-3 Agonist: mirabegron (Myrbetriq): interacts with drugs
that induce CYP2D6, potential adverse effects is increased BP.
Minimally invasive procedures: consider for clients with urgency
incontinence that does not respond to behavioral interventions or
medications. Referral to urology is needed. Procedures include:
OnabotulinumtoxinA bladder injections
Instilled in office via cystoscope.
Percutaneous tibial nerve stimulation
Electrical stimulation via acupuncture needle
Weekly appointments for 3 months
Stress incontinence: Urethral bulking
Surgery
Stress incontinence: Midurethral mesh sling
Urgencys incontinence: Sacral neuromodulation: implanted
electrode connected to a stimulator.
Urinary tract infection
o Bacteriuria: bacteria in urine
o Pyuria: Greater than 10 WBC per high-power field in urine sample
o Asymptomatic bacteria (ASB): Bacteria in urine, with or without pyuria, without
genitourinary symptoms or signs. Asymptomatic bacterial colonization of the
urinary tract increases with age and is found frequently in residents of long-
term care facilities.
o Symptomatic UTI: Pyuria and bacteriuria in the presence of at least two
signs/symptoms of UTI.
o Most common bacterial infection in adults over 65.
o Most common cause of sepsis in older adults.
o UTI’s in community-dwelling older adults: dysuria, frequency, urgency, and
hematuria. Post-menopausal women may complain of incontinence, nocturia,
low back pain, and constipation. Older adults may experience changes in
cognition, including confusion.
o Urine dipstick to evaluate for bacteriuria and pyuria is required. If
nitrites/leukocytes are present, treat symptoms until culture results to prevent
antibiotic resistance.
o UTI’s in LTC: May not present with typical UTI symptoms. More likely to have
chronic urinary symptoms such as frequency, nocturia, and incontinence.
Change in mental status may be the most common symptom. Other symptoms
include change in urine character, fever, declining functional status, and
hematuria.
o McGeer Criteria for LTC UTI diagnosis: Acute dysuria or Fever >37.9 plus
urgency, frequency, suprapubic pain, gross hematuria, CVA tenderness, or
, urinary incontinence.lllloooooooo
o Loeb Criteria for LTC UTI diagnosis (three of the following): Fever >38,
new/increased burning/frequency/urgency, new flank or suprapubic pain,
change in character of urine, new or worsening mental status changes
Benign prostatic hyperplasia
o Multifactorial disease process involving smooth muscle hyperplasia, prostate
enlargement, and bladder dysfunction influenced by signals from the CNS.
o Age is the most common risk factor.
o Non-cancerous condition in which the prostate becomes enlarged with age.
Extremely common in men older than 60 and usually accompanied by lower
urinary tract symptoms.
o Develops gradually over years and symptoms appear slowly.
o Common symptoms: frequent urination, urgent urination, weak or interrupted
urine stream, inability to completely empty bladder.
o Cause is unknown but it is associated with changes in hormone levels as men
age. Increased androgen (male hormone) lead to cell proliferation in prostate
tissue surrounding the urethra. As the prostate enlarges, increased pressure on
urethra can obstruct urine flow and cause discomfort.
o Digital rectal examination (DRE) is essential assessment for BPH. Used to assess
prostate size, contour, and presence of abnormal nodules.
o International Prostate Symptom Score: measures the severity of lower urinary
tract symptoms. 7 or less = mild symptoms. 8-19 = moderate symptoms. 20-35
= severe symptoms. Not a diagnostic tool, just severity.
o Risk factors: Age, difficulty starting/stopping stream, dribbling, nocturia,
incontinence
o Presents with smooth, enlarged prostate during DRE.
o Treatment:
5-a-reductase inhibitors (finasteride) decreased ejaculate volume and
libido, teratogenic to the male fetus.
A-Adrenergic antagonist (tamsulosin) abnormal ejaculation (ejaculation
failure, reduced ejaculate volume or retrograde ejaculation). Risk of
floppy-iris syndrome during cataract surgery.
o Refer to urology.
o Prostate imaging and post-void residuals.
o Surgical interventions if there is renal insufficiency, urinary retention, recurrent
UTI’s, recurrent bladder stones, or gross hematuria.
Prostate cancer
o Second most common form of cancer among men in U.S.
o Age is the most common risk factor.
o Prostate tends to increase in size in an aging man.
o Black men have higher rates than men of other races. They are twice as likely to
die from the disease and tend to develop it at a younger age. They also tend to
have a more severe type of prostate cancer than men of other races.
o Clients are often asymptomatic during the early stages of the disease.
o Later symptoms include lower urinary tract symptoms.
o Risk factors: age, race (black), family history.
o Screening: discuss screening with all men aged 55-69 with a life expectancy of
at least 10 years. Start discussing at age 45 with men at higher risk (black men,
family history). Discuss risks and benefits.
o Death rates are low. No variance in rates among those who are screened and
those who are not.
o Typically slow growing and do not require treatment.
, o Elevated PSA levels may indicate other conditions such as BPH or prostatitis,
and some prostate cancers do not cause elevated PSAs.
o If they want to screen: PSA EVERY TWO YEARS.
o PSA should be below 4!!!
o Presents with firm nodules on prostate during DRE.
o DRE only allows you to feel the posterior prostate, does not ensure there are
not nodules on the anterior or lateral prostate.
o Hormonal treatment is the mainstay of management of metastatic prostate
disease.
Erectile dysfunction
o The inability to get and/or maintain a penile erection that is firm enough for
sexual relations. It can be due to physical or psychological causes that affect any
of the areas of the brain, reproductive hormones, emotions, nerves, muscles,
and/or blood vessels that are involved with the phenomenon of erection.
o Most common physical causes: heart disease, atherosclerosis, high blood
pressure, nerve damage, stroke. Most common psychological causes: stress,
anxiety, depression, communication issues with sexual partner.
o Phosphodiesterase type 5 inhibitor (PDE5i) Sildenafil (Viagra): Increases and
preserves cyclic guanosine monophosphate (cGMP) levels in the penis, thereby
making the erection harder and longer lasting.
If used daily can cause BPH due to smooth muscle relaxation.
Education: sexual stimulation is required to obtain erection, go to ED
for painful erections lasting more than 4 hours, avoid grapefruit juice,
take 1 hour before sexual activity. Caution if pre-existing cardiovascular
disease. If anginal pain, lightheadedness, or other symptoms occur
during sex refrain from sexual activity and report to provider. Stop
taking if a sudden loss of vision or hearing loss occur.
DO NOT USE WITH NITRATES- contraindicated.
Tadalafil has the longest duration of action.
Monitor for: tinnitus, vertigo, hearing loss assessments, pulmonary
edema, eye examination for visual acuity, assessment of color vision,
pupillary response, fundoscopic exam, heart rate and blood pressure
checks.
Initiate at a lower dose for age 65 and older.
o Risk factors: cardiovascular (hypertension, coronary artery disease,
hyperlipidemia, peripheral vascular disease), DM, depression, obesity, alcohol
use, medication use (antihypertensives, antidepressants, antiandrogenic
agents), history of pelvic surgery/trauma/radiation, neurologic diseases,
endocrinopathies (hyper/hypothyroidism, hypogonadism, corticosteroid use).
o History:
International Index of Erectile Dysfunction (IIED): 15 questions,
addresses all domains of male sexual dysfunction.
Sexual Health Inventory for Men: short version (5 questions) of IIED.
o Physical exam:
Femoral and peripheral pulses for strength and bruit.
Assessment for penile plaques.
Hair growth patterns, gynecomastia, or small testes.
Cremasteric Reflex. (used to determine if the cause of ED is
neurological. Alzheimer’s disease, stroke, and certain medications can
interfere with nerve signals.
Visual field defects may indicate pituitary tumors.
o Diagnostic testing such as HGBA1C, thyroid function, and lipid panel may reveal
