elimination (2) Flashcards
defecation
process of waste elimination
feces
semisolid mass of fiber, undigested food, inorganic food
bowel elimination process:
fece material reaches rectum, stretch receptors initiate contraction of the sigmoid colon/rectal muscles, internal anal sphincter relaxes, sensory pulses cause bearing down, external sphincter relaxes
factors in bowel elimination
personal, hydration/nutrition, developmental stage, medication, surgery/procedures, pregnancy, exercise, and pathological conditions
what is the main factor of bowel elimination
hydration and nutrition
promoting normal bowel movement
nutrition, hydration, positioning/timing, privacy, and exercise
bristol stool scale
classifying of poop
valsalva manuever
process of bearing down, pushing on the vagus nerve, decreased blood pressure and rate and result in passing out
separate, hard lumps
constipation
sausage-like and lumpy
mild constipation
sausage-like with cracks on surface
healthy
smooth, snake shape
healthy
soft blob, clear-like edges
lack of fiber
fluffy and mushy, ragged edges
mild diarrhea
watery, entirely liquid
diarhhea
components of a complete bowel assessment
nursing history, physical assessment, review relevant test results, patient’s medical history, chewing ability, recent stressors/illnesses, and environmental situation
constipation
uncomfortable or infrequent bowel movements, hard stools
impaction
stool you can’t pass, constipation that has gone untreated
diarrhea
stool is more watery
incontinence
inability to control feces or urine
flatulence
gassy
hemorrhoids
ulcers, enlarged blood vessels - straining to poop
promoting normal BM
exercise, nutrition/hydration, positioning, timing (often after eating)
incontinence
inability to control urine or feces
void
to urinate
void
micturate
dysuria
painful or difficult urination
hematuria
blood in urine
nocturia
frequent night urination
polyuria
large amounts of urine
proteinuria
presence of large protein in urine
urinary frequency
voiding at frequent intervals
urinary urgency
need to void all at once
hesitancy
difficulty initiating urination
dribbling
leakage of urine despite the voluntary control of urination
retention
accumulation of urine in bladder without the ability to completely empty
residual
urine remaining post void > 100 mL
______ stool, the patient feels the urge to go but unable to do so and liquid stool seeps out around the impaction
impacted
involuntary constriction and relaxation of muscles of the intestine is _____
peristalsis
what does fiber do for stool?
it absorbs water, swells, and softens hard stool
at which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter?
tubing injection port
cloudy urine indicates?
infection, sedimentation, or high levels of protein in the urine
regulatory function of the kidneys is ____ and _____
acid-base function and fluid/electrolyte balance
clarity of urine for hematuria
dark, smokey
clarity of concentrated urine is
orange-amber
____ stimulates secretion of aldosterone
hyperkalemia
____ is associated with increased levels of ADH
hypochloremia
____ will ____ urine volume and cause fluid retention
ADH, decrease
what odor can indicate an UTI or possible renal failure
strong ammonia
what physiological changes can occur with aging and cause stress incontinence
estrogen deficiency and weakening of the urinary sphincter
on a residual urine test, you will instruct the patient to do what?
empty the bladder before a urinary catheter is inserted
signs of rehydration include
increased urinary output and dilution of the urine, which results in decreased specific gravity
monitoring what, is the most important in a patient with diarrhea
fluid and electrolyte balance
if ADH is high, it
causes more water to be absorbed creating a high concentration by small volume of urine
if ADH is low, it
causes more water to be excreted creating a large volume of urine
ADH is produced by the
pituitary gland
aldosterone is produced by the
adrenal gland
aldosterone does what?
regulates water reabsorption and changes urine concentration by increasing sodium reabsorption and helps control secretion of potassium
kidneys produce approximately how many mL an hour
50-60 mL
normal voiding is typically how many times per day, depending on fluid intake
5-6x
dark yellow urine is often indicative of
dehydration
certain medications like ____ & ____ can cause orange urine
rifampin and phenazopyridine
urine is ___ from consumption of aspargus
greenish
promoting normal urination
provide privacy, assist with positioning, bladder schedule/toilet routines, fluids/nutrition, monitor for skin break down, kegel exercises
characteristics of urine
color, clarity, and odor
record ALL fluids -intake
semi-solid foods, ice chips, IV fluids, fluids, tube feeding, irrigations instilled and not immediately removed
record ALL fluids - output
fluid loss via emesis (vomiting), urine output, diarrhea, and drainage from suction or wounds
