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Foundations of Nursing > Elimination > Flashcards

Elimination Flashcards

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1
Q

What is the function of the kidneys?

A

Remove and filter waste from blood and produce urine

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2
Q

What is the function of the ureters?

A

Transport urine from the kidneys to the bladder

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3
Q

What is the function of the bladder?

A

store urine

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4
Q

What is the function of the urethra?

A

Transport urine out of the body

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5
Q

Micturition

A

urination

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6
Q

What is the minimum urine output?

A

30 mL/hour

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7
Q

Oliguria

A

<30 mL/hour urine output for 2 or more hours

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8
Q

Polyuria

A

urine output of 3L/24 hours (3,000 mL)

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9
Q

Anuria

A

no urine production

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10
Q

Incontinence

A

involuntary loss of urine

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11
Q

Functional Incontinence

A

loss of continence because of causes outside of the urinary tract

ex. sensory impairments, cognitive impairments, altered mobility, altered manual dexterity (arthritis), environmental barriers,

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12
Q

Stress Incontinence

A

involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent sphincter

ex. coughing, laying down, laughing, exercising, walking, getting up

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13
Q

Overflow/Chronic Incontinence

A

involuntary loss of urine caused by an overdistended bladder

ex. distended bladder on palpation, nocturia, high postvoid residual, frequency, involuntary leakage

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14
Q

Urge/Urgency Incontinence

A

involuntary passage of urine associated with strong sense of urinary urgency

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15
Q

Transient Incontinence

A

caused by medical conditions that in many cases or treatable and reversible

ex. inflammation, medications, delirium, depression, fecal impaction, urinary retention, mobility impairment

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16
Q

Reflex Incontinence

A

occurs at predictable intervals when specific bladder volume is reached

ex. absent awareness of bladder filling and the urge to void, leakage of urine without awareness, may not completely empty the bladder because of dyssynergia of the urinary sphincter

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17
Q

Urinary Retention

A

Inability to partially or completely empty the bladder; Urine accumulates in bladder.

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18
Q

Urinary Tract Infection (UTI)

A

Infection in any part of the urinary system; May result from catheterization or procedure

Most common bacteria associated with UTIs: E.coli

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19
Q

Urinary Diversion

A

Diversion of urine to external source

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20
Q

What influences bladder function?

A

Brain structures

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21
Q

What are the factors influencing urination?

A
  • Disease conditions
  • Diagnostic examinations
  • Personal habits
  • Growth and development
  • Medications
  • Surgical/medical procedures
  • Sociocultural factors
  • Psychological factors
    (anxiety, stress, privacy)
  • Fluid intake/balance
    • Nocturia, polyuria,
      oliguria, anuria
    • Diuresis: increased
      or excessive
      production of urine;
      often produced as a
      treatment
    • Fever
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22
Q

Cultural Aspects

A
  • Each patient is unique
  • Some cultures prefer
    same gender
  • Privacy Important
  • Interpreter/ written in
    primary language
  • Hygiene: right hand or
    left hand?
  • Female circumcision
  • Family involvement
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23
Q

Nocturia

A

frequent urination at night

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24
Q

Diuresis

A

increased or excessive production of urine; often produced as treatment

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25
Q

Pyuria

A

pus in the urine

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26
Q

Dysuria

A

painful or difficulty urinating

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27
Q

Post Void Residual (PVR)

A

amount of urine left in the bladder after urination

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28
Q

Bladder capacities:

A
  • Ranges from 600 to 1,000 mL of urine
  • Adults normally void every 2 to 4 hours
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29
Q

Medications can cause

A
  • urinary retention or overflow incontinence (anesthesia/opioids)
  • urgency and incontinence (Lasix)
  • change of the color of urine (pyridium)
  • diuretics
30
Q

Physical Assessment/Recognizing Cues of urination

A
  • urine: COCA
  • HPI
  • kidneys: flank pain with infection or inflammation
  • bladder: distended bladder rises above symphysis pubis
  • urethral meatus: observe for discharge, inflammation, and lesions
  • skin and mucosal membranes: assess hydration
31
Q

Assessment/Recognizing Cues of urination through laboratory/diagnostic exams

A
  • urinalysis
  • urine culture and sensitivity
  • cystoscopy
  • radiologic procedures
    • Kidneys, Ureter,
      Bladder (KUB)
    • Computerized
      tomography (CT)
    • Intravenous
      pyelogram (IVP)
    • Ultrasound
32
Q

Assessment/Recognizing Cues: Look at urine

A
  • intake and output
  • urine collection
    • random sample
      (routine urinalysis)
    • clean catch (sterile
      cup)
    • sterile (straight
      intermittent catheter
      and indwelling foley
      catheter)
    • timed
33
Q

Assessment/Recognizing Cues: Urinary Retention

A
  • distended abdomen
  • reports of pressure
  • restlessness
  • no UO or scant for hours
34
Q

Interventions: Urinary Retention

A
  • bladder scanner
  • postvoid residual
35
Q

CAUTI

A

Catheter, Associated, Urinary, Tract, Infection
- Hospital acquired
- Does the patient really need this?
- High risk for infection
- portal of entry

36
Q

Preventing CAUTI

A
  • Use aseptic technique
    with sterile equipment
  • Secure indwelling
    catheters to the
    patient’s leg
  • Maintain closed
    drainage systems
  • Do not allow any
    obstruction of urine
    flow
  • Urine bag BELOW
    level of bladder
  • Urine bag NEVER
    touches the ground
  • Empty urine bag when
    ½ full, clean tip with
    alcohol
  • Perform perineal &
    catheter care
37
Q

Indications for Urinary Catheter (not indwelling)

A
  • Obtain sterile
    specimen (intermittent
    “straight cath”)
  • Hourly monitoring
  • Unable to void
  • Surgical procedures
  • Instillations of
    medications into the
    bladder
38
Q

Inappropriate Indications for Urinary Catheter

A
  • nurse convenience
  • incontinence
39
Q

Assessment/ Recognizing Cues: UTI

A
  • Frequency
  • Burning (dysuria)
  • Urgency
  • Foul smelling urine
  • Cloudy urine
  • Elderly-confusion
40
Q

Interventions: UTI

A
  • Patient teaching
  • Fluids
  • Voiding schedule
  • Women wipe front to
    back
  • Avoid tight clothing,
    bubble baths
  • Drink 6-8 glasses of water/fluids per day
41
Q

Catheter Care Skills

A
  • Keep meatus free of
    secretions/encrustation
  • Pericare and cleansing first 4” of catheter
  • Every 8 hours or less
  • After defecation
  • Some agencies use chlorhexidine (CHG) wipes
  • The skill can be delegated but the assessment can NOT be delegated (if pt has had surgery to the area or trauma…do NOT delegate)
42
Q

Assessment/Recognizing Cues: Indwelling Catheter

A
  • Assess COCA
  • Assess urethral meatus & catheter
  • Males
  • Assess patient for S/S of UTI
  • Assess patient’s knowledge for catheter care
  • Offer patient to perform self-care
43
Q

Female External Catheter

A

Pros
- no UTIs in study
- no reported discomfort
- no skin breakdown associated
- better sleep (not wet at night)

Cons
- confused may remove
may slip out of very thin women

44
Q

Male External Catheter

A

Pros
- independent
- no suction required
silicone gel brands do not require tape

Cons
- careful with uncircumcised men’s foreskin
- may leak
- tape may cause injury

Requires physician order

45
Q

Plan of Care Problems (NANDA)

A
  • Functional urinary
    incontinence
  • Stress urinary
    incontinence
  • Urge urinary
    incontinence
  • Overflow urinary
    incontinence
  • Risk for infection
  • Toileting self-care
    deficit
  • Impaired skin integrity
  • Impaired urinary
    elimination
  • Urinary retention
46
Q

Plan of Care Implementations urination
RESTORATIVE CARE

A
  • Strengthening pelvic
    floor muscles
  • Health Promotion
    Education
  • Habit training
  • Catherization/Self-
    catheterization
  • Maintenance of skin
    integrity
  • Promotion of comfort
47
Q

Implementation Care for Older Adults

A
  • Offer toileting every 2 hours
  • Encourage to empty bladder before and after meals and at bedtime.
  • Encourage to ↑ fluid intake 6-8 glasses/day unless contraindicated.
  • No Fluids (except with meds) 2 hours before bedtime
48
Q

Indications for Renal Dialysis

A
  • renal failure that can no longer be controlled by conservative management
  • worsening of uremic syndrome associated with end stage renal disease
  • severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures
49
Q

Plan of Care: Evaluation of Outcomes

A
  • Evaluate whether the
    patient has met
    outcomes and goals.
  • Check how the patient
    reports progress
    made
  • Help the patient
    redefine goals if
    necessary
  • Revise nursing
    interventions as
    indicated
50
Q

Bladder Scanner

A
  • It is best practices to
    look for urinary
    retention
  • It avoids invasive and
    painful catherization
  • It uses portable
    ultrasound and tells
    the amount of urine in
    the bladder
  • Tells amount of urine in the bladder without catheterization
51
Q

Plan of Care Implementations: Urination
HEALTH PROMOTION

A
  • Drink 6-8 glasses of
    water a day
  • Limit caffeine
  • To prevent nocturia,
    avoid drinking 2
    hours before bedtime
  • Practice good voiding
    habits
  • Every 3-4 hours while
    awake, proper
    positioning
  • Empty completely
  • Keep bowels regular
  • Prevent UTI
  • Stop smoking
52
Q

Factors affecting bowel elimination

A
  • age
  • fluid intake
  • diet
  • psychological factors
  • personal habits
  • physical activity
  • position during defecation
  • pregnancy
  • pain
  • surgery and anesthesia
  • medications, laxatives, and cathartics
  • diagnostic tests
53
Q

Constipation

A

infrequent stool, dry, hard stool difficult to eliminate

54
Q

Impaction

A

collection of hardened feces wedged in rectum that can’t be expelled

55
Q

Diarrhea

A

increase in number of stools, passage of liquid, unformed feces

56
Q

Inconstinence

A

inability to control passage of feces and gas

57
Q

Flatulence

A

accumulation of gas in the intestines

58
Q

Hemorrhoids

A

dilated, engorged veins in lining of rectum

59
Q

Bowel Diversion

A

temporary or permanent artificial opening in the abdominal wall

60
Q

Assessment/Recognizing Cues: Bowel Movement

A

Health History
- Bowel habits
- Medications
- Recent illness
- Stressors
Physical assessment
- Abdomen & GI tract
Laboratory Diagnostics
- Stool C&S
- Fecal occult blood test (FOBT)
- CT scan
- Endoscopy
- Magnetic Resonance - Imaging (MRI)
- Barium Swallow/Enema

61
Q

Plan of Care Problems: Bowel Movement

A
62
Q

Related Factors of Constipation

A
  • Sedentary lifestyle
  • Overuse of laxatives
  • Inadequate diet
  • Inadequate fluids
  • Pain
  • Psychological
63
Q

Implementations of Bowel Movement

A

Health Promotion
- Promotion of normal defecation
- Establish a routine an
hour after a meal or
maintain the patient’s
routine
- Sitting position
- Privacy
- Positioning on bedpan

64
Q

Bulking Form Laxative

A

absorbs liquid for soft stool; psyllium, methylcellulose

65
Q

Emollient Laxative

A

detergent that softens stool; docusate sodium

66
Q

Osmotics

A

draws water into the stool; saline, magnesium citrate, polyethyleneglycol

67
Q

Stimulant

A

increases intestinal mobility; bisacodyl, castor oil

68
Q

Anti-diarrheal

A

decreases muscle tone to the decreasing passage of feces; diphenoxylate (lomotil)

69
Q

Enemas

A
  • Cleansing
    • Tap water
    • Normal saline
    • Hypertonic solutions
    • Soapsuds
  • Oil retention
  • Others: carminative & Kayexalate
70
Q

Enema Administration

A
  • Sterile technique
    unnecessary
  • Wear gloves
  • Explain the procedure
  • Positioning
71
Q

Digital Removal of Stool

A
  • Use if enemas fail to remove an impaction
  • Last resort for constipation
  • Provider’s order needed
  • Risk for cardiac dysrhythmia

have to be on their left side

72
Q

Continuing and Restorative Care: bowel movement

A
  • Bowel training
    • Training program
    • Diet
    • Promotion of regular
      exercise
    • Management of
      hemorrhoids
  • Skin integrity

Foundations of Nursing (6 decks)

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