Elimination Flashcards
Urinary Assessment: History
pattern changes, weight changes
Urinary assessment: Problems
frequency, difficulty starting, nocturia
Urinary Assessment: Existing Issues
medications, comorbilities
Urinary Assessment: urine assessment
color, odor, flaoters
Incontinence
Involuntary loss of urine
Incontinence: Complications
skin breakdown, mental health
Incontinence: Patient Education
Drink fliuds from 0600 - 1800
limit alcohol/caffeine/citric juice intake
take diuretics in the morning
kegal excersises
Incontinence: Nursing care
Skin care, Clean Linens, Peri Care
Rentention
Unable to void urine
Rentention: Complications
bladder distention
Urinary tract infections
Rentention: Patient Education
void when urge is present
stay hydrated
Rentention: Nursing care
assist pt to comfortable position
privacy/adequate time to urinate
bladder scan/ in & out catheter
Straight/ In & Out Catheter
No ballon: sterile collection: acute retention
Foley Catheter
ballon: indwelling
Coude Catheter
Catheter with curved tip for enlarged prostate
Condom Catheter
tip 1-2 in from end of cath; change daily
Purewick
External cath for women, vaccum at 40, urethra to top 1/3 of cath; change daily
Urinalysis
not sterile; void into clean bed pan/container or clean catch
Urine Culture
Sterile; if foley, draw from port or clamp < 30 mins to allow urine to reach port, in & out cath if no foley
Fecal Assessment: History
Pattern changes, color, form, diet, stress level
Fecal Assessment: Problems
constipation, diarrhea
Fecal Assessment: Existing Issues
medications, bleeding, comorbidities
Fecal Assessment: Abdominal Assessment
bloated, soft/hard, tenderness, bowel sounds
Constipation
Consistantly hard to pass
Constipation: Complications
Nausea, vomiting, impaction
Constipation: Patient Education
2 L oral fluids per day
20-30g fiber per day
consistant excersise
Constipation: Nursing Care
administer fluids/ balanced diet
ambulation
Diarrhea
more than 3 loose stools per day
Diarrhea: Complications
Nausea, vomiting, dehydration, bleeding
Diarrhea: Patient Education
2L oral fluid per day
avoid caffeine and alcohol
Diarrhea: Nursing Care
administer fluids
assess for dehydration
electrolyte replacement
Restoring Normal Bowel Patterns
bedpan/bedside commode
enema
excersise
diet/nutrition
positioning
Fecal Occulating Blood Test
detects blood in stool that isn’t visible; color change = blood
stool culture
sterile; use sterile bedpan/container; used to detect infection
Ostomy
opening in GI tract through the surface of the skin
Ostomy: Why it’s needed
cancer, surgery, lifestyle changes, meds not working
Ostomy: Whats it look like
stoma- red/pink, moist
some swelling, serosanguineous fluid = normal
no severe pain or abdominal distention
Ostomy: Education
how to change bag/system
diet: avoid gassy food
support groups
Ostomy: Nursing Care
Empty when 1/2 to 1/3 full
skin is priority
Minimum Amount of Urine output
30 mL per hour
Types of Output
Urine
Emesis
Liquid Stool
Tube Drainage
Wound Drainage
Blood
What counts as intake
anthing you drink, IV fluids
How much water per day
2000 mL per day
Intake/Output Process
Measure
Document (mL)
Discard
Peri care (if needed)
Types of Enemas
How to postion pt for enema
Saline Enema
Oil Enema
Sims’ position
