Exam 3 Flashcards
Progression of Oxygen
Room air -> face mask - venturi - nonrebreather - ambu
No face mask for COPD
What does normal gas exchange look like?
- O2
- breathing effort
- AP diameter
- Breath sounds
- O2 between 95% and 100%.
- Breathing is quiet and effortless
- Anteroposterior (AP) diameter of the chest is approximately a 1:2 ratio of AP to lateral diameter.
- Breath sounds are clear bilaterally
Hypoxia vs Anoxia vs Ischemia
Hypoxia: insufficient oxygen in blood
Anoxia: cessation of gas exchange; absence of oxygen in blood
Ischemia: oxygen-deprived tissues; insufficient oxygen is supplied to meet the requirements of the myocardium.
Three steps in oxygenation (and their definitions)
1.Ventilation is the movement of air into and out of the lungs. (Inspiration and expiration)
2. Transport is the ability of hemoglobin to carry O2 and CO2 gases between the lungs and the blood.
3. Perfusion is the ability of blood to transport oxygen from the capillaries in the lungs body tissues and organs and return deoxygenated blood to lung
8 causes of impaired ventilation
- Unavailable oxygen
- High altitudes
- Disorders of lungs, airways, respiratory muscles (COPD, anaphylaxis)
- Hyperventilation (fast removal of CO2)
- Hypoventilation (insufficient removal of CO2 or intake of O2)
- Rib fracture (pain reduces inhalation)
- Muscle weakness (prevents full thoracic expansion)
- Cervical spinal cord injury (limits movement of diaphragm)
4 causes of impaired transport of Oxygen
- Reduced RBCs (Anemia, acute blood loss)
- Reduced amount of Hgb in blood
- Hemolytic anemias (destruction of RBCs by spleen seen in sickle cell disease)
- Inability of tissues to extract oxygen seen in cyanide poisoning
5 causes of impaired perfusion
- Decreased cardiac output (shock)
- Thrombi, emboli
- Vessel narrowing, vasoconstriction
- Dysrhythmias (ischemia, anxiety, drug toxicity, caffeine, alcohol, tobacco)
- Blood loss
9 physiological risk factors for impaired gas exchange
- anything that increases metabolic demand (Fever, pregnancy, obesity, wound healing, exercise)
- Neuromuscular or Musculoskeletal abnormalities (chest wall movement; muscular dystrophy)
- Trauma (Flail chest or barrel chest-barrel chest from overuse of accessory muscles)
- CNS alterations (C5 injury impairs chest expansion)
- Cardiac disorders (heart failure)
- Hypoxia from hypovolemia
- Chronic diseases (emphysema, COPD)
- Immunosuppression (cancer, aplastic anemia, medication)
- Altered mental status (increases aspiration risk)
6 lifestyle factors for gas exchange
- Tobacco Use (biggest preventable cause of death including secondhand smoke)
- Nutrition (moderate carbs, low fat, high fiber)
- Exercise (you want 150 minutes a week of moderate intensity and 2 days of muscle strengthening
- Substance Abuse (decreases respiratory center AND may have poor nutrition)
- Stress (increases metabolic rate and O2 demand and increased RR and cardiac output; may trigger asthma)
- Hospitalization (trachs bypass innate defenses, prolonged bed rest reduces thoracic expansion)
3 Nonmodifiable risk factors for gas exchange
- Age (toddlers due to tendency to put things in their small airways and older adults due to stiffening and calcification of valves and ventricles)
- Air pollution (smog, occupational pollutants (asbestos, talcum powder, dust, airborne fibers))
- Allergies
10 things to assess in physical exam for gas exchange
- Respiratory rate, depth, effort (Shortness of Breath, Pursed lip breathing)
- Oxygen saturation
- Use of accessory muscles
- Nasal flaring
- Cough
- Auscultation of lung sounds: wheezes, Rhonchi, crackles, stridor
- Color – cyanosis, pallor
- Level of consciousness
- Nails-clubbing
- Shape of chest- barrel shape with COPD
6 Early signs of Hypoxemia
- Tachypnea
- Tachycardia
- Restlessness, anxiety, confusion
- Pale skin, mucus membranes
- Hypertension unless from shock
- Use of accessory muscles, nasal flaring, adventitious breath sounds
7 Late signs of Hypoxemia
- Stupor
- Cyanotic skin, mucus membranes
- Clubbing seen in cystic fibrosis, Congenital heart defect
- Bradypnea
- Bradycardia
- Hypotension
- Cardiac dysrhythmias
Pulse oximetry (what is it, what is it for, normal range)
- Noninvasive measurement with instant feedback
- Measures pulse saturation (SpO2)
- SpO2 expected range 95-100%; <90% hypoxemia
5 reasons for low SpO2
- Hypothermia
- Poor blood flow
- Low Hgb
- Edema
- Nail polish (dark nail polish more problematic)
4 diagnostic tests for gas exchange
- Chest X-ray, CT and MRI scans
- Lung scan-identify abnormal masses by size and location
- Bronchoscopy, Bronchial wash-visual exam of tracheobronchial tree to obtain fluid, sputum, biopsy
- Ventilation/Perfusion(V/Q) scan- pulmonary function test; determines ability of lungs to exchange oxygen and CO2; differentiates pulmonary obstructive from restrictive disease
4 laboratory tests for gas exchange
- CBC (WBC)–# and type of RBCs, WBCs, and hemoglobin to assess anemia and oxygenation ability
- Blood culture
- Arterial blood gases-Ph, CO2, O2, HCO3
- Sputum specimens-identify microorganisms, in lungs
Sputum Collection Process (3)
- Have patient take a couple of deep breaths and cough up mucus into sputum cup.
- You want lung “butter” not spit from oral cavity.
- If patient is not able to do this, then it can be obtained through nasotracheal suctioning with a sputum trap device attached. (RT or nurse can do; required order b-c patient may vagal/faint)
Vaccinations (primary prevention) for gas exchange (3 notes)
-flu vaccine
-pneumococcal
-immunize those at high risk or in contact with high risk
7 tertiary preventions for Dyspnea Management
- Treatment of underlying process
- Pharmacology
- Oxygen therapy
- Relaxation techniques
- Biofeedback
- Meditation
- Cardiopulmonary reconditioning (Coughing and deep breathing techniques)
4 tertiary preventions for airway maintenance
- Hydration to prevent and thin secretions
- Proper coughing to remove secretions and keep airway open
- Chest physiotherapy
- Suctioning
4 Pharmacotherapy for gas exchange (name the drugs)
- Bronchodilators Ex: Albuterol (Proventil, Ventolin)
- Corticosteroids Oral- Prednisone, Inhaled- Fluticasone (Flovent)
- Long-acting beta-agonist (LABA) Ex: Symbicort, Advair
- Nebulizers
Coughing and Deep Breathing Techniques
Note on post abdominal surgery
Frequency (2)
- Splint if post abdominal surgery; patient takes few deep breaths, splints (to reduce pain) then coughs before you listen to lungs
- Frequency (q2h for COPD, upper respiratory infection when awake; every hour if a lot of sputum)
2 types of Chest Physiotherapy
-percussion (with nurse’s hand)
-vibration (with tool i.e., vest)
Postural drainage
Drainage, positioning, and turning to improve secretion clearance and oxygenation
-position depends on which lobe is drained; position so side that needs draining is up
When to suction? (4)
- Unable to clear secretions by expectoration
- Gurgling respirations
- Sputum collection if patient unable to cough productively
- Do not suction regularly because foreign objects can increase secretions, risk for infection
4 suction techniques (which to do first?)
- Oral (Yankauer) suction tube (clean technique)
Other suctioning techniques (sterile technique and do first):
- Oropharyngeal and nasopharyngeal
- Orotracheal and nasotracheal- no artificial airway present
- Tracheal- through artificial airway
4 Noninvasive methods to promote Lung Expansion (and their benefit)
- Ambulation-increases general strength and lung expansion
- Positioning 45 degree-reduces stasis of secretions and decreased chest wall expansion; Promotes adequate ventilation and oxygenation
- Incentive Spirometry- voluntary deep breathing IN via visual feedback to patients about inspiratory volume; reserved for those with atelectasis or at risk after surgery
- Positive expiratory pressure (PEP): airway clearance requiring exhalation against resistance to get air behind mucus
2 invasive mechanical ventilations (artificial airways and usage)
- Endotracheal is short-term, removed within 14 days
- Tracheostomy is surgically or percutaneous inserted for prolonged mechanical ventilation which may interfere with vocalization
Noninvasive mechanical ventilation (2 and when to use)
- CPAP (continuous positive airway pressure)-benefits those with sleep apnea, heart failure, preterm with underdeveloped lungs
- BiPAP (Bilevel positive airway pressure)-provides assistance during inspiration and prevents alveolar closure during expiration
Aerosol Mask-breathing treatment i.e nebulizer
Flow rate
FiO2
3 notes
- Flow rates at least 10 L/min
- FiO2 24-100%
- Provides high humidification with O2 delivery
- Medication delivery
- Put it back on the oxygen flow amount and device after treatment -IMPORTANT
How to use incentive Spirometer (5)
How often to use?
- Set up yellow marker
- Patient exhales completely
- Patient seals mouth and inhales slowly and deeply
- Patient should inhale until they cannot anymore then hold for 6 seconds
- Then takes mouth off and exhales
At least 4 times a day, 10 times an hour
4 tips on Positioning for gas exchange
- Elevate HOB- Position (45-degree semi-Fowler’s)
- Change positions often and prevent sliding down bed
- If lung collapse, put good lung down
- If abscess or hemorrhage, put bad lung down
7 Tips for oxygen therapy
- Use humidification if above 4 L to avoid drying out nose
- Need order since therapeutic gas (device, number of liters of oxygen and/or sat to maintain)–
- Monitor respiratory rate and pattern, LOC, SpO2, ABGs and notify provider as necessary
- Provide oxygen therapy at the lowest liter flow rate that manages hypoxia
- Takes 5 minutes for change in O2 sat to be noticed
- Decrease the FiO2 as the client’s SpO2 improves
- Can delegate nasal cannula or face mask but nurse still assess response
5 Adverse effects of oxygen
- Nonproductive cough
- Sternal pain
- Nasal stuffiness
- Sore throat
- Hypoventilation
8 safety precautions for Oxygen
- No smoking
- Keep at least 10 feet from open flames
- Ensure working smoke detectors
- Do not use oil-based products (petroleum products, Vaseline)
- Use water-soluble gel to prevent dry nares
- When using oxygen cylinders, secure them so they do not fall over.
- Check oxygen level of portable tanks before transporting a patient should be 75% full
- Ensure patient has adequate oxygen tubing
Ambu Bag
3 purposes
- CPR (Chest compression, Earl defibrillation, Establish airway and rescue breathing)
- Rescue Breathing
- Manual Ventilation
Face Tent
Flow rate
FiO2
Purpose
2 notes
- Flow rate 8-12 L/min
- FiO2: highly variable; 28% - 100%
- Purpose: controlled concentration of oxygen and increase moisture for patients who have facial burn or broken nose, or who are claustrophobic
- Notes: Covers the nose and mouth; Does not create a seal around the nose
Simple Face Mask
Flow rate
FiO2
Purpose
4 disadvantages
- Flow rate 6-12 L/min; Minimum flow 5 L/min
- FiO2 35-50%
- Purpose: short-term use
- Disadvantages: Therapy interrupted with eating and drinking; Increased risk of aspiration, Comfortable unless claustrophobic, contraindicated for pts who retain CO2
Nasal Cannula
Flow rate
FiO2
Main concern (3 tips to address)
3 Advantages
- Most common
- Low flow O2 (1-6 L/min)
- FiO2 24-44%
- Concern: Skin
- 3 tips to address concern: Pad pressure points; Lubricate nares; Humidify > 4 L/min
- Advantages: safe, simple, does not impede talking or eating
Non-rebreathing mask
Flow rate
FiO2
Purpose of valve
2 advantages
3 disadvantages
- Flow rates 10-15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration
- FiO2 60-90%
- Valve between mask and reservoir bag-prevents mixing of exhaled air with oxygen administered
- Advantages: Useful for short period, does not dry mucous membranes
- Disadvantages: Contraindicated for COPD, may irritate skin; hot, confining
Venturi mask
Flow rate
FiO2
3 Advantages
- Flow rates 4-12 L/min
- FiO2 24-50%
- Benefits: High-flow delivery system; Delivers the most precise oxygen concentration; Good for COPD who need low, constant O2
Pursed-lipped vs diaphragmatic breathing
-definition
-goal/useful in who?
- Diaphragmatic Breathing: Increases tidal volume and decreases respiratory rate; useful for those with dyspnea secondary to heart failure -> belly out, inhale, belly in, exhale
- Pursed-lipped breathing: deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse
9 Symptoms of Pneumonia
- Viral –nonproductive cough or clear sputum
- Bacterial- productive cough of white, yellow, or green sputum
- Fever
- Chills
- dyspnea on exertion
- sharp, stabbing chest pain upon inspiration
- Rhonchi or crackles may be heard on auscultation.
- Children may have retractions and nasal flaring.
- Older Adults may have confusion
Pathophysiology of Pneumonia (3)
- Inflammation of terminal bronchioles and alveoli is triggered by infectious organisms and inhalation of irritating agents
- WBCs go to area of infection, causing local capillary leak, edema, and exudate
- Reduces GAS EXCHANGE and leads to hypoxemia (need blood culture)
6 Risk Factors for Community-acquired pneumonia
- older adult
- never received the pneumococcal vaccination or received it more than 5 years ago
- Did not receive the influenza vaccine in the previous year
- chronic health problem or other coexisting condition that reduces immunity
- Recent exposure to respiratory viral or influenza
- Use of tobacco or alcohol or exposed to high amounts of secondhand smoke
Causes of Community-acquired pneumonia
- 3 most common agents
- Treatment lengths
- Most common bacterial agents: streptococcus pneumoniae, HIB— empirical antibiotics
- Most common viral: influenza, RSV
- Treatment length: minimum five days
9 Risk Factors for Health care-acquired pneumonia
- Is an older adult
- chronic lung disease
- presence of gram-negative colonization
- altered LOC
- Recent aspiration event
- IV therapy, wound care, antibiotics in past 30 days
- poor nutritional status
- reduced immunity
- Usage of drugs that increase gastric pH (histamine [H2] blockers, antacids) or alkaline tube feedings
- in hospital >48 hrs in past 90 days
Management for Health Care-acquired pneumonia (5)
- Provide adequate hydration
- Assess risk for aspiration using evidence-based tool
- Monitor for early signs of sepsis
- Hand hygiene
- Provide vigorous oral care
Ventilator-acquired pneumonia
Onset
Risk increases because of what? (2)
- 48-72 hrs after trach
- presence of ET tube increases risk by bypassing protective airway mechanisms and allowing aspiration of secretions from oropharynx and stomach
- dental plaque also increases risk
Management of Ventilator-acquired pneumonia (6)
- Elevate HOB 30 degrees
- Daily sedation and weaning assessment
- DVT prophylaxis
- Oral care regimen
- Stress ulcer prophylaxis
- suctioning
What is Atelectasis? (2)
- Collapse of alveolar lung tissue which prevents normal exchange of O2 and CO2
- Incomplete expansion of a lung or portion of the lung
5 causes of Atelectasis
- Airway obstruction (mucus plug in airway or by compression by fluid, tumor mass, exudate)
- Lung compression (pneumothorax or pleural effusion)
- Increased recoil of the lung due to loss of pulmonary surfactant
- Breathing high concentrations of oxygen increases the rate gases are absorbed from the alveoli
- Hypoventilation (reduced volume of O2)
9 signs of Atelectasis
- Rapid, shallow breathing/ tachypnea
- Dyspnea
- Cough
- Fever
- Decreased chest expansion on affected area
- Leukocytosis
- Breath sounds (Crackles over involved lobes of lungs, decreased or absent breath sounds, Wheezing)
- Trachea shift to affected side may be present if the collapsed area is large
- Use of accessory muscles causing fatigue
3 forms of patient education
-unplanned/informal (nurse-patient on age-specific screenings, medication, discharge teaching)
-formal classes (smoking cessation, diabetes education )
-self-directed (internet sources and instructional videos; nurse role to answer questions, review materials for accuracy, and assist patient to locate high quality info)
Difference in Cognitive, psychomotor, and affective learning domains
-definition
-examples of each
- Cognitive: increases knowledge of subject, thinking processes; may include reading materials, lectures, Q/A session, role-play
- Psychomotor: requires patient to manipulate and simulate manual or physical skills; may include demonstrations, practices; may include demonstration, practice, return demonstration, independent projects
- Affective: changes in attitudes, valued and beliefs; focus is receiving and characterizing; may include role-play, one-to-one or group discussion
Health Belief Model of Patient Education (Rosenstock)- (3 points)
three primary points of this model are:
1. The individual’s perception of his/her susceptibility to and the severity of the disease are the primary motivators to learn and change behavior.
2. A belief must exist that the illness can be avoided, and that taking action can reduce the risk.
3. The individual must also believe that he/she can make the necessary changes to improve their health
- Modifiable factors demographics, social, psychological variables must exist
Health promotion model of Patient Education (3)
- Focus is on optimizing wellness versus avoiding disease.
- Patient motivation is influenced by social support and competing priorities.
- Patient perceptions of benefit and the ability to succeed can impact outcomes.
Nurse’s role in Patient Education (5)
- Empower Patient (collaborate)
- Assist the patient in developing mutual and relevant goals and learning objectives
- Assess patient readiness/needs, environment, motivation, and ability (Consider their background, culture when making goals)
- Plan educational interventions to achieve goals
- Evaluate patient outcomes toward goal attainment
TJC’s SPEAKUP campaign
Speak up about questions or concerns
Pay attention to the care you get.
Educate Yourself about your illness
Ask others to be your advocate
Know about your medicine
Use a quality health care organization
Participate in all decisions
4 Factors that influence patient’s ability to learn
- Motivation (values)
- Ability (Physical symptoms, anxiety)
- Environment
- Readiness (attitude, grief)–biggest
Maslow’s Hierarchy of Needs
Lower-level needs must be met before attempting to address higher-level needs.
* Self-actualization
* Self-esteem/ego
* Social / love and belonging
* Security (comfort)
* Physiological (pain)
Health Literacy
-Definition
-How to assess
- What to do if patient unable to read
cognitive and social skills that determine ability of individual to gain access to, understand and use info to promote and maintain good health; Strong predictor of health status; stronger that SES, age, race, educational level
- Assess by asking patient to read medication label, brochure
- If patient unable to read, nurse needs alternate methods
3 Factors influences patient’s readiness to learn
- loss, grief, health status (Patients cannot learn when they are unwilling or unable to accept a loss or their illness)
- Impaired Attentional set: mental state that allows a learn to focus on and comprehend a learning activity
- Physical discomfort, anxiety, confusion, and environmental distractions
What to consider for psychomotor learning? (5)
Consider patient’s size, strength, coordination, sensory acuity, energy level
Ideal Learning environment (6)
- Number of people included in the session—max 5-6
- Noise level- low
- Privacy-close cubicle curtains
- Room Temperature- good ventilation
- Furniture in room-arrange groups so individuals face one another
- Lighting in room- well-lit
5 patient barriers to learning and teaching
- Lack of social support systems
- Lack of financial resources
- Time
- Frequent interruptions
- Distractions, noise
6 ways to stimulate senses and maintain learning in patient education
- Change tone and intensity of voice
- Make eye contact
- Use gestures that accentuate key points of discussion
- Move around room
- Use relaxation and deep breathing if patient anxious
- Active participation
Telling in Patient Education (3)
Teaching approach
- Teach information in limited time frame
- Outlines task with clear, concise instructions
- No opportunity for feedback
Ex. Preparing for emergency surgery
Participating in Patient Education (2)
Teaching approach
- Collaborative with nurse and patient
- Patient has opportunity for discussion, feedback, mutual outcome setting, revision of teaching plan
Entrusting in Patient Education (2)
Teaching approach
- Patient takes accountability for their learning
- Nurse is available for support and to observe patient’s progress without introducing new info
Reinforcing in patient education (3)
Teaching approach
- Use of stimulus to Increase probability of desired response
- More likely to repeat behavior with reinforcement
- Positive > negative b-c negative can discourage participation or lead to withdrawal
Smoking Cessation and Patient education
Goal
Teaching Topics (3)
Interventions (6)
- Goal: assist smokers to stop their use of cigarettes and other forms of tobacco. (Formal teaching)
- Teaching topics: dangers, risks, complications of tobacco use
- Interventions: Nicotine replacement, Behavior modification, Counseling, Support, Relapse prevention, cessation plan
Discharge teaching and Patient education
Goal
Nurse’s role (3)
Information patient needs (5)
Goal: ensure patient transitions to the setting in which health care needs can be appropriately met (informal teaching)
Nurse role: Begins on admission and provided consistently so learning is reinforced; know plan of care ASAP, inform patient and family
Patients require the following instruction before they leave health care facilities:
* Safe and effective administration of medications and any equipment
* Counseling on nutrition and modified diets
* Access to available and appropriate community resources including referrals
* When to notify the healthcare provider for changes in functioning of new symptoms
* Post-hospital destination (determined by case manager)
Diabetes Management and Patient education
Goal
Location
Teaching Topics (6)
- Goal: to increase the patient’s ability to self-manage this endocrine disorder (formal teaching)
- Facilitated through group classes and one-on-one teaching in hospital or community
Teaching topics:
* Physiological alterations present in the disease
* Diet
* Medication management
* Monitoring of blood glucose
* Risk reduction
* Psychosocial impact
Documentation for Patient Education (3)
- Includes information taught and to who i.e., patient, family
- Document patient’s motivation, ability to learn, patient’s response, and resources.
- Include detailed plan and goal progression for other health care providers to reinforce if the education is to be continued across care settings.
5 Methods to Evaluate Learning
- Observe patient’s performance
- Ask evaluative questions, phrased carefully to guide patient to identify or describe info
- Surveys and questionnaires for affective behavior change
- Teach back technique (with nonjudgmental language, ownership of insufficient teaching)
- Return demonstration for psychomotor
One-on-one Discussion as an Instructional Method (3)
- Active participation
- Consider patient’s learning styles, literacy, and culture
- Use diagrams and pamphlets
Group Discussion as an Instructional Method (5)
- Most economical
- small group (<6) effective
- Involves instruction and discussion
- Leads to deeper understanding, longer retention, increased peer support
- Not all patients benefit so individualize
Demonstration as an Instructional Method (2)
- Usage of psychomotor skills
- Most effective when educator does skill then return demonstration
Analogies as an Instructional Method (3)
- Useful to teach complex ideas and concepts
- Acknowledge patient’s background, experience, and culture to keep analogies relevant
- Keep simple and clear
Roleplay as an Instructional Method (2)
- Apply knowledge in safe controlled environment
- Rehearsing desired behavior to enhance patient comfort with it
7 things to assess in learner’s assessment
- Education level
- Literacy level
- Social support
- Resources
- Developmental level
- Generational differences
- Culture
Transient Urinary Incontinence Nursing Interventions (2)
Look for reversible causes
Notify healthcare provider
Functional Urinary Incontinence Nursing Interventions (5)
- Adequate lighting in bathroom,
- Mobility aids (raised toilet, walker, etc)
- Elastic waist pants with no zipper or button
- Use of incontinence containment product
- Keep call light in reach
Overflow Urinary Incontinence Nursing Interventions (4)
- Timed void
- double void
- monitor post void residual
- intermittent catheterization if severe retention
Stress Urinary Incontinence Nursing Intervention
Instruct patient to do pelvic floor exercises (Kegel exercises)- squeeze anus as if to hold in gas
Urge Urinary Incontinence Nursing Interventions (4)
- Ask patient about symptoms of UTI
- Avoid bladder irritants, caffeine, artificial sweeteners
- Do pelvic floor exercises
- bladder training
Reflex Urinary Incontinence Nursing Interventions (4)
- Follow a prescribed regimen of emptying the bladder – either through voiding or intermittent catheterization.
- Place urine containment devices such as pads, condom catheters, purewix
- Monitor for signs and symptoms of UTI
- Monitor for autonomic dysreflexia; life threatening.
Transient Urinary Incontinence (6 causes)
Caused by delirium, urinary tract infection, medications, hyperglycemia, CHF, mobility impairment
Happens suddenly, unusual for patient and reversible
Functional Urinary Incontinence Causes
Causes outside the urinary tract or patient control, related to functional deficits (mobility), manual dexterity, cognitive impairment, poor motivation, environmental barriers, can be result of caregiver not responding
Overflow urinary incontinence (2 causes and 3 symptoms)
Caused by overdistended bladder which may happen with urinary retention, poor bladder emptying due to pelvic floor weakness, weak bladder contractions
Symptoms: distended bladder, high postvoid residual, nocturia
Stress Urinary Incontinence (3 causes, one note)
Small volumes of urine loss due to increased intraabdominal pressures, trauma after childbirth, weakness of urinary structures.
Usually does not happen at night
Urge Urinary Incontinence
Urgency, frequency, nocturia, difficulty holding urine, leaks on the way to bathroom
Leaks larger volume, strong urges like when one hears water running, drinks liquids
Reflex Urinary Incontinence (what is it? who is most at risk?)
Diminished or absent awareness of the bladder filling, leakage of urine without awareness, may not completely empty the bladder due to Synergia
At risk for autonomic dysreflexia- affects people who are para or quadriplegic.
3 Nursing Considerations for Routine Urinalysis
- Collect during normal voiding or from an indwelling catheter or urinary diversion collection bag.
- Use a clean specimen cup.
- In some health care settings, you may be responsible for testing urine with reagent strips. Follow manufacturer instructions when performing and reading the strips. Dip the reagent strip into fresh urine, then observe color changes on the strip. Compare the color on the strip with the color chart on the reagent strip container.
Process for Clean-voided or midstream urine test (6)
- Urine may be collected by the patient after detailed instruction on proper cleansing and collection technique
- Always use a sterile specimen cup.
- Patient performs perineal care first (females hold labia open)
- Patient urinates a bit into toilet
- Patient then urinates in cup
- Remove cup before urine stops and before releasing labia
5 Nursing Considerations for Sterile specimen for culture and sensitivity urine test
- If the patient has an indwelling catheter, collect a sterile specimen from special sampling port found on the side of the catheter. Never collect the specimen from the drainage bag.
- Clamp the tubing below the port for 10-15 minutes, allowing fresh, uncontaminated urine to collect in the tube.
- After wiping the port with an antimicrobial swab, insert a sterile syringe hub and withdraw at least 3–5 mL of urine
- Patients with a urinary diversion need to have the stoma catheterized to obtain an accurate specimen.
- A preliminary report will be available in 24 hours, but usually 48–72 hours is needed for bacterial growth and sensitivity testing.
7 Nursing Considerations for Timed specimen for culture and sensitivity urine test
- The timed period begins after the patient urinates and ends with a final voiding at the end of the time period.
- In most 24-hour specimen collections, discard the first voided specimen and then start collecting urine.
- Patient voids into a clean receptacle, and the urine is transferred to the special collection container, which often contains special preservatives.
- Depending on the test, the urine container may need to be kept cool by setting it in a container of ice.
- Each specimen must be free of feces and toilet tissue.
- Missed specimens make the whole collection inaccurate.
Urgency and 4 common causes
immediate and strong desire to void that is not easily deferred
- Full bladder
- Urinary tract infection
- Inflammation or irritation of the bladder
- Overactive bladder
Dysuria and 5 common causes
Pain or discomfort with voiding
- Urinary tract infection
- Inflammation of the prostate
- Urethritis
- Trauma to the lower urinary tract
- Urinary tract tumors
Frequency and 6 common causes
- High volumes of fluid intake
- Bladder irritants (e.g., caffeine)
- Urinary tract infection
- Increased pressure on bladder (e.g., pregnancy)
- Bladder outlet obstruction (e.g., prostate enlargement, pelvic organ prolapse)
- Overactive bladder
Hesitancy and 2 common causes
Delay in start of urinary stream when voiding
- Anxiety (e.g., voiding in public restroom)
- Bladder outlet obstruction (e.g., prostate enlargement, urethral stricture)
Polyuria and 4 common causes
Voiding excessive amounts of urine
- High volumes of fluid intake
- Uncontrolled diabetes mellitus
- Diabetes insipidus
- Diuretic therapy
Oliguria and 4 common causes
Diminished urinary output in relation to fluid intake
- Fluid and electrolyte imbalance (e.g., dehydration)
- Kidney dysfunction or failure
- Increased secretion of antidiuretic hormone (ADH)
- Urinary tract obstruction
Nocturia and 6 common causes
Awakened from sleep because of urge to void
- Excess intake of fluids (especially coffee or alcohol before bedtime)—avoid 2 hours before bedtime
- Bladder outlet obstruction (e.g., prostate enlargement)
- Overactive bladder
- Medications (e.g., diuretic taken in the evening)
- Cardiovascular disease (e.g., hypertension)
- Urinary tract infection
Dribbling and 3 common causes
Leakage of small amounts of urine despite voluntary control of micturition
- Bladder outlet obstruction (e.g., prostatic enlargement)
- Incomplete bladder emptying
- Stress incontinence
Hematuria (gross vs microscopic)
4 common causes
- Gross hematuria (blood is easily seen in urine)
- Microscopic hematuria (blood not visualized but measured on urinalysis)
- Causes
o Tumors (e.g., kidney, bladder)
o Infection (e.g., glomerular nephritis, cystitis)
o Urinary tract calculi
o Trauma to the urinary tract
3 Causes of urine retention
- Bladder outlet obstruction (e.g., prostatic enlargement, urethral obstruction, perineal trauma after childbirth)
- Absent or weak bladder contractility (e.g., neurological dysfunction such as caused by diabetes, multiple sclerosis, lower spinal cord injury)
- Side effects of certain medications (e.g., anesthesia, anticholinergics, antispasmodics, antidepressants)
Acute vs chronic urinary retention
Acute retention: Suddenly unable to void when bladder is adequately full or overfull
Chronic retention: Bladder does not empty completely during voiding, and urine is retained in the bladder
5 Effects of Urinary Retention
- painful, stretched bladder, feelings of pressure
- Backflow to the upper urinary tract
- Dilation of the ureters and renal pelvis
- Pyelonephritis and renal atrophy
- Overflow incontinence
3 causes and 3 effects of bowel retention
Causes: ignoring urge, decreased peristalsis, blockage
Effects: hardened and dry stool, constipation, impaction
Primary Prevention for Elimination (5)
- Hydration (water softens stool; increases urine volume to reduce bladder irritation; avoid excess)
- Adequate dietary fiber (prevent stool retention; 25 g a day)
- Regular and timely toileting practices (prevents constipation and urinary incontinence or retention; holding urine can lead to UTI)
- Regular exercise (increases peristalsis)
- Avoidance of environmental contamination (parasites in water and food that is not prepared properly)
Colonoscopy Screening
Age recommendation
Stool-based test (Frequency)
Direct visualization tests (what is it? Frequency)
-begins at 50 and stops at 75
- Stool-based tests (guaiac-based fecal occult blood test, fecal immunochemical test, or multitargeted stool DNA test) are recommended annually at rectal exam
- Direct visualization tests include colonoscopy or sigmoidoscopy allow direct visualization of the colon and removal of precancerous lesions, averting the development of colon cancer. These are recommended every 10 years (or more often with certain risk factors).
Prostate Cancer Screening (2)
- periodic prostate-specific antigen (PSA)-based screening of men ages 55 to 69 is individual decision
- USPSTF recommends against in above 70 years
Tertiary Interventions for Incontinence (8)
- Bladder or bowel retraining
- Biofeedback to help gain control
- Timed and prompted voiding (great for dementia)
- Use of protective pads (great for dementia)
- Skin care (great for dementia)
- Fluid intake management
- Avoid medications that contribute to problem
- Avoid indwelling catheter
Surgical Interventions for Bowel Elimination
Colectomy
Colostomy or ileostomy
Rectal prolapse Repair
Hemorrhoidectomy
Fecal collection system
- Colectomy: removing a portion of the bowel and reattach colon
- Colostomy/ileostomy: Diversion of the intestines (colon or small intestine) through a stoma on the due to injured or diseased intestine, colon, or rectum.
- Rectal prolapse repair: when the rectum falls into or through the anal opening due to weak muscles or excess straining; surgical repair if regularly occurs or significant discomfort. most common among young children and the elderly.
- Hemorrhoidectomy: excision of hemorrhoids if topical treatments and changes in diet do not eliminate their associated discomfort. T
- Fecal collection systems. a flexible tube inserted into the rectum that is used to collect liquid stool in patients with incontinence who are not candidates for bowel retraining or have Clostridium difficile
Surgical Interventions for Urinary Elimination
Catheterization
Stents
Removal of renal calculi (3 procedures)
Prostate Surgery (2)
Bladder surgery (3)
Urinary Diversion
- Urinary catheterization: placement of tube through urethra into bladder to drain urine; invasive and required medical order and aseptic technique
- Stents: rigid tubes that provide an opening that is not normally present, used internally in the urethra and externally as part of anastomosis procedures performed for bladder cancer; maintain the patency of pathways for urinary elimination.
- Removing renal calculi: lithotripsy (fragmentation of the stones through sound waves); endourologic procedures (crushing the stones); or open procedures in which an incision is made, and the stone is surgically removed.
- Prostate surgery. An enlarged prostate can cause significant urinary obstruction; transurethral resection of the prostate or Prostatectomy refers to the removal of the prostate and is usually performed among younger men diagnosed with prostate cancer, particularly if diagnosed in early disease stage.
- Bladder surgeries: laser surgery, transurethral resection, and partial or total cystectomy.
- Urinary diversion: diverting the ureters to a urinary stoma on the skin (usually on the abdomen)
Antibiotics and Urinary Elimination
Most common (3)
Purpose
Precaution
Most common for UTI: ciprofloxacin, trimethoprim with sulfamethoxazole, nitrofurantoin
Purpose: treatment or prophylaxis of infection or urinary retention
Precaution: decrease intestinal bacterial flora leading to diarrhea
Diuretics and Urinary Elimination
Common types (3)
Caution with who?
Common types: loop (furosemide), thiazide, potassium-sparing
Caution with renal disease
Antispasmodics and Elimination
Common types (2)
Purpose
Precaution
Common types: Loperamide/Imodium (for diarrhea), oxybutynin
Purpose: anticholinergics that relieve smooth muscle spasms in urinary incontinence, IBS, diarrhea
Precaution: may increase risk for urinary retention
Medication for Constipation
Common types (6)
Precaution
Common types: bulk-forming agents, bowel stimulants, lubricants, stool softeners, laxatives (docusate sodium, bisacodyl), enemas
Precaution: bowel can become dependent on laxatives and stimulants for impulse to defecate; discontinue as soon as elimination achieved
Analgesics and Elimination
Conditions that cause pain with elimination (6)
Main drug
Precaution for analgesics (2)
Conditions: UTI, kidney stones, cystitis, bladder spasms, hemorrhoids, rectal fissures
Main: phenazopyridine (changes urine orange, for uti)
Precaution: hypnotics and sedatives may reduce ability to recognize urge to void; opioids may lead to constipation
Growth and development factors which impact Urinary Elimination
-Children
-pregnancy
-older adults (2)
- Readiness for toilet training includes ability to recognize the feeling of bladder fullness, hold urine for 1 to 2 hours, and communicate the sense of urgency usually around 18-24 months
- Pregnant women have increased frequency and reduced capacity due to hormonal changes and pressure of fetus on bladder
- Older adults have decrease in bladder capacity, increased bladder irritability, and an increased frequency of bladder contractions during bladder filling.
- Older adults are at increased risk for urinary incontinence because of chronic illnesses and factors that interfere with mobility, cognition, and manual dexterity.
Sociocultural factors which impact Urinary Elimination (4)
- Americans expect toilet facilities to be private, whereas some cultures accept communal toilet facilities.
- Social expectations (e.g., school recesses, work breaks) can interfere with timely voiding.
- The need for privacy and adequate time to void can influence the ability to empty the bladder adequately. (close doors, ask visitors to leave)
- Left hand for unclean procedures in some cultures
Conditions which impact Urinary Elimination
-Diabetes, multiple sclerosis and stroke
-Arthritis, Parkinson’s dementia, chronic pain
- Spinal cord injury or intervertebral disk disease
-prostate enlargement
- Diabetes mellitus, multiple sclerosis, and stroke can alter bladder contractility and the ability to sense bladder filling (bladder overactivity or deficient bladder emptying)
- Arthritis, Parkinson’s disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet.
- Spinal cord injury or intervertebral disk disease can cause the loss of urine control because of bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter.
- Prostatic enlargement (e.g., benign prostatic hyperplasia [BPH]) obstructs bladder outlet
Diagnostics and Surgeries which impact Elimination
Abdominal surgery (2)
Anesthesia
Cystoscopy (2)
Colonoscopy
- Local trauma during lower abdominal and pelvic surgery can obstructs urine flow and cause ileus (stop peristalsis for 24-48 hrs)
- Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness and peristalsis, causing urinary retention and constipation
- Cystoscopy may cause localized trauma of the urethra and transient (1 to 2 days) dysuria and hematuria.
- Colonoscopy: required empty bowel and may lead to increased gas or loose stools until normal eating pattern resumed
Intake and Output
Normal Amount
Minimum Amount (if less what 3 things may it indicate)
Normal timing (what if longer?)
Normal Amount: 2300 mL in 24 hrs
Minimum Amount: 30 mL/ hr (if less, may be sign of impending death, bladder or kidney dysfunction, or fluid imbalance)
Normal timing: every 3-6 hours; if longer urinary retention
Odor of Urine (3)
- Ammonia in nature (more ammonia smell the longer it stands)
- Foul odor may be UTI; garlic, asparagus
- More concentrated the stronger the odor (more concentrated in morning or with ECF deficit)
Clarity of urine (4)
- Transparent unless pathology is present
- Cloudy if urine stands for several minutes or early in morning
- Thick and cloudy with bacteria or WBCs
- Foamy urine indicates protein in urine caused by high blood pressure or renal disease
Color of Urine
-Normal
- Red (3)
- Bright red
- Dark red
- Dark amber
- Bright orange
-Normal: pale straw to amber color
- Red: beets, rhubarb, blackberries
- Bright red: bleeding from bladder, urethra, or prostate w/ catheter
- Dark red: bleeding from kidneys or ureters
- Dark amber: high concentration of bilirubin in patients with liver disease
- Bright orange: phenazopyridine
Urinary Collection Devices (4)
- 2000 mL collection bag for urinary catheter
- Foley catheter with a urometer- has a box and bag-used to collect hourly outputs or more precise measurement of urine
- Urinal-used for men who can void on their own-might need help with emptying it-can measure
- Nuns cap-used for patient who can go to bedside commode or commode in room for measuring-turn backwards in toilet for a stool sample; Monitor-record and empty frequently
Urinalysis Findings
Specific Gravity (3 reasons when high and 3 when low)
pH
WBC
Casts (what are they and when seen)
- Specific gravity-concentration of particles in urine
- High= Dehydration, increased ADH secretion, reduced renal blood flow
- Low= Overhydrated, early sign of renal disease, inadequate ADH secretion
- pH- usually acidic; if urine stands for a while—becomes more alkaline;
- WBC- if over 4 indicates infection or inflammation
- Casts-cylindrical bodies not normally present, types are hyaline, RBCs, WBCs, granular cells, and epithelial cells which all indicates renal disease
Urinalysis Findings (When are the following present?)
Leukocyte esterase
Crystals (2)
RBC (5)
- Leukocyte esterase-key with kidney stones
- Crystals- kidney stones or high uric acid (gout)
- RBC/hematuria- damage to glomeruli or tubules, presence of catheter, period may have leaked into it, surgery, cancer
