Exam 3 Flashcards
why are women at a greater risk for UTI?
shorter urethra
- developmental considerations
- food and fluid intake
- psychological variables
- activity and muscle tone
- pathologic conditions
- medications
factors affecting micturtion
Toilet training 2-3 years old, enuresis (bed-wetting)
May see child potty trained sooner also
children developmental considers (micturtion)
Nocturia: urinating at night
Increased frequency
Urine retention and statis
Voluntary control affected by physical problems
effects of aging on micturtion
- anuria
- bacteriuria
- dysuria
- enuresis
- frequency
- hematuria
- hesitancy
- incontinence
- nocturia
- oliguria
- polyuria
- proteinuria
- urgency
problems associated with changes in voiding
urine output <50 mL/day
possible etiology: acute or chronic renal failure
anuria
what is the normal volume of urine that should be voided per hour?
30 mL
bacterial count >100,000 colonies/mL in the urine
etiology: infection
bacteriuria
painful or difficulty voiding
etiology: lower UTI, inflammation of the bladder or urethra, acute prostatitis, stones, foreign bodies, tumors in bladder
dysuria
involuntary voiding during sleep
often seen in pediatric pt
etiology: delay in functional maturation of CNS
enuresis
frequent voiding - more than every 3 hr
frequency
RBC in urine
hematuria
delay, difficulty in initiating voiding
hesitancy
involuntary loss of urine
incontinence
awakening during the night to urinate
nocturia
urine output <0.05 mL/kg/h
oliguria
increased volume of urine voided
polyuria
protein in urine
proteinuria
strong desire to void
urgency
which conditions relate to urinary output
1) polyuria
2) anuria
3) oliguria
which conditions relate to urine composition?
1) hematuria
2) bacteriuria
3) glucosuria
4) proteinuria
1) intake 3L of water
2) generally recommended to drink 6-8 cups of water per day - consider indirect intakes of water
3) normal output is 1 mL/kg/hr; oliguria is 0.5 mL/kg/hr
urine output
multiply weight (in kg) by 0.5 and subtract amount voiding
if weight is given, then do based on pt weigh to see if urine output is normal
if UO is given, but no weight, then go on general basis that 30 mL (or CC) /her is normal
how to calculate urine output
fluids can be lost through many sources: urine, feces, seat, evaporation via lungs
intake: water, coffee, juice, tea, IV, foods
I & O
- pt w/ CHF
- sign on door to notify everyone about restrictions
strict I&O
- voiding patterns, habits, past history of problems
- what color is your urine?
- do you frequently get UTI?
- how frequent? is it painful?
urine assessment
- Physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; and examination of urine
- Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment.
- Urinary bladder: Palpate and percuss the bladder or use a bedside scanner.
- Urethral orifice: Inspect for signs of infection, discharge, or odor.
- Skin: Assess for color, texture, turgor, and excretion of wastes.
- Urine: Assess for color, odor, clarity, and sediment.
physical assessment of urine/bladder/kidneys
Explore its duration, severity, and precipitating factors
Note the patient’s perception of the problem
Check the adequacy of the patient’s self-care behaviors
Assessing a problem with voiding
- Voiding: within normal pattern
- Urine: Color: straw-colored; Consistency: clear; Odorless
- Bladder: not distended
- Catheter type: Indwelling (in patient; foley)/ straight (doesn’t have foley bag, removed after releasing bladder)/ 3-way (bleeding in the bladder; 2 bags of saline, one foley bag)/ suprapubic
- Secured? or Patency: patent (free-flowing)
NANDA Normal Urinary Findings
Dysuria
Polyuria
oliguria
Impaired Urinary Elimination
Caused by factors outside the urinary tract
Functional urinary incontinence
Overdistention and overflow of bladder
Overflow urinary incontinence
Emptying of the bladder without sensation of need to void
Reflex urinary incontinence
Involuntary loss of urine related to an increase in intra-abdominal pressure
Stress urinary incontinence
Overactive bladder, sudden desire to urinate
Urge urinary incontinence
Urine not coming out
Symptoms: distended bladder, No urinary output; may see anuria or oliguria, Pain
Nursing intervention
- Bladder scan: noninvasive ultrasound
- Over 400 cc of urine –> straight cath
Urinary retention
True or False: Urinary Incontinence is a normal part of aging
False
- Produce sufficient quantity of urine to maintain fluid, electrolyte, and acid-base balance
- Empty bladder completely at regular intervals without discomfort
- Provider care for urinary diversion and know when to notify physician
- Develop plan to modify factors contributing to current or future urinary problems
- Correct unhealthy urinary habits
Patient Goal Urinary Elimination
- Maintaining normal voiding habits: schedule, urge to void, privacy, position on toilet/bedpan, hygiene
- promoting fluid intake
- strengthening muscle tone: Kegel, pelvic floor muscles
- assisting with toileting
Promoting normal urination
A postoperative client hasn’t been able to void. The provider has ordered a foley catheter. Nurse can facilitate insertion by asking client to:
bear down as if trying to void
A urine specimen from a patient with an indwelling catheter should be obtain from the collection receptable. True or False
False
A pt with an indwelling urinary catheter is suspected of having a UTI. The nurse should collect a urine specimen for urinalysis and culture and sensitivity by
Clamp drainage tube below the post, using sterile needle, aspirate a specimen of urine via the port
If you have a pt who is available to follow instructions (A&O 3 or 4)
- Instruct pt to clean urethral orifice
Female anatomy: front to back
Male anatomy: starting from tip clean from center outward (circular motion outwards)
- Before voiding in the cup, will tell pt to pee a little bit then place cup underneath
Clean Catch
- Urinary retention
- Prolonged patient immobilization
- Obtaining urine specimen when patient is unable to void voluntarily
- Accurate measurement of urinary output in critically ill patients
- Assisting in healing open sacral or perineal wounds in incontinent patients
- Surgery
- Providing improved comfort for end-of-life care
Reasons for Catheterization
- Female
- Sexually active (and diaphragm)
- Menopause
- Catheters
- Co-morbidities that affect immune system
- Anything leading to urinary stasis in bladder
Risk for UTI
- Explain reason for diversion and rationale for treatment
- Demonstrate effective self-care behaviors
- Describe follow-up care and support resources
- Report where supplies may be obtained in the community
- Verbalize related fears and concerns
- Demonstrate a positive body image
Pt Education for Urinary Diversion
- Normal is 1.015-1.025
- If it is low –> dilute; too much water
- If it is high –> concentrated; pt may be dehyrdated
- The higher it gets, the more concentrated, closer to amber color
Urine specific Gravity (USG)
- pink = hematuria, kidney damage, anticoagulants, drank too much ginger tea
- tea color/brown = sever kidney or liver failure
- orange = medication (ex, Rofampin)
- black = medication (ex, Iron or Levadopa)
- blue = medication (ex, amytriptaline)
urine color
- ensure easy access to bathroom or commode
- discourage fluid intake at bedtime
- discourage alcohol use before bedtime
- evaluate medication regimen and schedule, particularly diuretics and drugs that produce sedation or confusion
- use a night light
- use clothing that is easily removed for voiding
- keep assistive ambulatory devices readily available
- evaluate gait and ability to ambulate safely
- asses for UTI
nursing strategies for nocturia
- maintain fluid intake of 1,5000-2,000 mL/day
- discourage sue of alcohol, artificial sweeteners, and caffeine
- provide easy access to the bathroom
- assess factors that influence voiding
- use assistive devices when necessary
- use collection devices when necessary
- ensure safety when ambulating
- encourage use of whole, unprocessed, coarse wheat bran to prevent constipation and fecal impaction
- perform pelvic floor muscle training exercises several times a day
- encourage participation in a bladder retraining program
nursing strategies for incontinence
- maintain liberal fluid intake
- encourage shower instead of tub bath to decrease opportunity for bacteria in bath water to enter urethra
- encourage appropriate perineal care and frequent changing of incontinence briefs
- void at frequent intervals; every 2 hours if possible
- void immediately after sexual intercourse
- women should avoid use of potentially irritating feminine products, such as deodorant sprays, douches, and powders in the genital area
nursing strategies for UTI
Nursing interventions for patient who has not voided for past 5 hours, on standard bladder protocol
1) Assist client with urinal or to bedside commode or bathroom
2) Encourage increase fluid intake
3) Assess with bladder scanner
4) Notify provider
5) Offer client straight catheter
- potassium is usually inside the cell
- sodium usually has high concentration outside of the cell
fluid components
- Risk for electrolyte imbalance
- Risk for imbalanced fluid volume
- Deficient fluid volume
- Risk for deficient fluid volume
- Excess fluid volume
- Risk for excess fluid volume
NANDA Dx for Fluids
- aka, hypovolemia, dehydration
- causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, or decrease fluid intake
- BP: lower w/ dehydration bc of loss of volume
- HR: increased with dehydration
- BUN: decreased
- USG: increased, urine will be concentrated
- Hematocrit: increased, not enough plasma
Deficient fluid volume
- Impaired cognitive function
- Fatigue
- Headache
- Dizzy
- Loss of skin or tongue turgor
- Hypotension, orthostatic hypotension
- Tachycardia, often with weak, thready pulse; Not enough fluid in body –> weak
- Dark urine, increased specific gravity, oliguria
- Decreased weight: Rapid loss of 1 kg (2.2 lbs) = loss of 1 L of fluid; 5-10% of weight is serious
signs of dehydration
- in the morning after voiding
- in hospital gown
- on same scale
weighing pt
- Refusal to drink for fear of incontinence
- Dementia or delirium
- Decreased sense of thirst with age
- Multiple meds, often with diuretics
- Frailty
- Reliance on others to supply fluids
elderly at greater risk for dehydration
Fluid overload (contributing factors: excessive dietary sodium or 0.9% NS containing IV solutions)
Diminished homeostatic mechanism (risk factors: heart, liver, or renal failure)
causes of excessive fluid volume (hypervolemia)
- Edema, 2+ Pitting?
- Distended neck veins, JVD
- Abnormal lung sounds - Crackles; Too much fluid - probably in lungs
- Tachycardia
- Thready pulse
- Increased blood pressure
- Increased weight: > 2 kg (4.4 lbs) in 2 days or 2.5 kg (5 lbs) in a weak
- Increased urine output
signs of hypervolemia
- Daily weights (Can be delegated)
- I&Os
- Lung sounds
- Edema
- Monitor responses to medications - diuretics (esp Potassium - connection to cardiac)
- Patient teaching related to sodium and fluid restrictions
- Promote rest
- Semi-fowlers position for orthopnea
- Skin care, positioning/turning
Nursing Management for hypervolemia
- Shift of fluids into transcellular compartments
- Pleural (pleural effusion)
- Peritoneal (Ascites)
- Leads to deficit in ECF volume
- Retention - holding onto fluid
third spacing
sodium <135
hyponatremia
sodium >145
hypernatremia
- isotonic
- lactated ringers
- dextrose
- hypotonic
- hypertonic
IV fluid types
- similar concentration of blood
- use when pt is dehydrated
- volume expander
- given to treat hypovolemia
- main medication is 0.9% NS
isotonic
- has electrolytes
- might be given for burns
lactated ringers
- D5
- given when sodium level is high
- 0.45% NS
hypotonic
- more solute; 3-5% NS
- dextrose: D10W
hypertonic
- Maintain daily fluid restriction 1500-2000 mL or 1.5-2 L
- Sodium < 2000 mg/day (note: 2300 mg in a teaspoon)
- Maintain urine specific gravity within normal range (1.010-1.025)
- Maintain urine output of 1 mL/kg/hr
possible expected outcomes for hypovolemia/hypervolemia
self-care activities such as bathing, dressing, toileting, transferring, continence, feeding
Activities of daily living (ADLs)
permanently contracted state of a muscle
Contractures
complication resulting from extended plantar flexion
Footdrop
the activities of daily living needed for independent living such as managing finances and meal preparation
Instrumental activities of daily living (IADLs)
exercise involving muscle contractions with resistance varying at a constant rate (muscle contraction with resistance)
Isokinetic exercise
exercise in which muscle tension occurs without a significant change in muscle length (muscle contraction without shortening)
Isometric exercise
movement in which muscles shorten (contract) and move (muscle shortening and active movement)
Isotonic exercise
complete extent of movement of which a joint is normally capable
Range of motion
- Assist patient with toileting
- Wash face with hands
- Provide mouth care
AM care before breakfast
- Toileting
- Oral care
- Bathing
- Special skin measures: lotion, barrier cream, no baby power
- Hair care
- Dressing
- Positioning for comfort
- Refreshing or changing bed linens
- Tidying up bedside
- Falls precautions
AM care after breakfast
- Offer individual hygiene measures as needed
- Change clothing and bed linens of diaphoretic patients
- Provide oral care every 2 hours if indicated
PRN care
- offer assistance with toileting, washing, and oral care
- Offer a back massage
- Change any soiled bed linens or clothing
- Position patient comfortably
- Ensure that call light and other objects patient requires are within reach
Hour of sleep (HS) care
used for pt with bad hips
fracture bedpan
- Clean from inner to outer canthus with wet, warm cloth, cotton ball or compress
- Use artificial tear solution or normal saline q4H if blink reflex is absent (unconscious patients)
- Care for eyeglasses or contact lens, if indicated
Eye care
- Wash external ear with washcloth-covered finger
- Preform hearing aid teaching and care if indicated
- Remove crusted secretions around nose by applying warm, moist compress
Ear and Nose Care
- Note any history of hair/scalp problems (e.g., dandruff, hair loss, baldness, alopecia)
- Shampoo and groom hair
Hair Care
- if the lens is not centered over the cornea, apply gentle pressure on the lower eyelid to center the lens
- gently pull the outer cornea of the eye toward the ear
- position the other hand below the lens to receive it and ask the patient to blink
rigid gas permeable (RGP) lenses
- have the pt look forward
- retract the lower lid with one hand. using the pad of the index finger on the other hand, move the lens down on the sclera
- using the pads of the thumb and index finger, grasp the lens with a gentle pinching motion and remove
soft contact lenses
- bathe the feet in mild soap and water
- avoid soaking the feet
- dry feet thoroughly, including the area between the toes
- apply moisturize to feet if they are dry
- use antifungal foot powder if necessary
- diabetic pt should file nails; avoid using scissors or nail clippers
- consult a podiatrist to cut nails
- wear appropriate footwear and cotton socks
- avoid using heating pads
foot care
1) isotonic
2) isometric
3) isokinetic
muscle contraction
active movement and ADLs
isotonic muscle contraction
muscle contraction without shortening, ex. wall sit or plank
isometric muscle contraction
muscle contraction with weights
isokinetic muscle contraction
1) aerobics
2) stretching
3) strengthening and endurance
4) movement and ADLs
body movement
- general ease of movement
- gait and posture
- alignment
- joint structure and function
- muscle mass, tone, and strength
- endurance
assessment of activity
- Activity intolerance
- Impaired transfer ability
- Risk for activity intolerance
- Risk for constipation
- Risk for injury
NANDA Dx Activity
- Ergonomics to prevent injury
- Safe patient handling and movement
- Safe transfer, equipment and assistive devices, E.g., gait belts, transfer devices, lifts
- Positioning patient in bed
- Devices for correct alignment, e.g., Foam wedges and pillows, trapeze, foot board or shoes (re: footdrop), hand roll, trochanter roll
- Protective positioning
- Repositioning Q2H
- Used graduated compression stockings (remove when bathing)
- Moving a patient up in bed
- Moving a patient from bed to stretcher or chair
- Assisting with active/passive ROM exercises
- Assisting with ambulation
Nursing Interventions for Activity
1) Verify the order
2) Patient identification and education
3) Hand hygiene
4) Collect the sample
5) Label the sample at the bedside (avoid errors)
6) Transport the sample to the lab
role of nurse in specimen collection
1) Verify the order
2) Patient identification and education
3) Prep as needed for the ordered test
4) Monitor the patient as needed post test
Role of nurse in imaging studies
evaluates the concentration, variety, and quantity of blood cells
complete blood count (CBC)
what is the reference range for WBC?
5,000-10,000 mm3
what is the reference range for hemoglobin?
12-18 g/dL
what is the reference range for hematocrit?
40-50%
- WBC count
- hemoglobin
- hematocrit
- RBC
- mean corpuscular volume
- mean corpuscular Hgb
- Mean corpuscular Hgb Concentration
- Red cell distribution width
- platelet count
CBC
- neutrophils
- lymphocytes
- monocytes
- eosinophils
- basophils
- band forms
differential blood panel
- sodium
- potassium
- calcium
- chloride
- CO2
- glucose
- blood urea nitrogen (BUN)
- creatinine
basic metabolic panel (BMP)
what is the sodium reference range?
135-145 mEq/L
What is the potassium reference range?
3.5-5.- mEq/L
What is the reference range for BUN?
8.0-20 mg/dL
What is the reference range for creatinine?
0.7-1.4 mg/dL
What is the reference range for creatinine?
0.7-1.4 mg/dL
what is BUN and creatinine indicative of?
kidney
what is the sodium lab indicative of?
hydration
what is the potassium lab indicative of?
cardiac
basic CBC + additional:
- albumin
- magnesium
- alkaline phosphatase
- ALT/SGPT
- AST/SGOT
- total bilirubin
complete metabolic panel (CMP)
what is the reference range for albumin and what is it indicative of?
3.5-5.5 g/dL and nutrition
what is the reference range for bilirubin and what is it indicative of?
0.3-1.9 mg/dL and liver
- Require immediate action
- Out of normal range
- Lab will call and tell the nurse the critical value –> nurse will repeat and confirm the lab value
critical lab values
Pt admitted to the emergency room complaining of fatigue and weakness. He reports large amounts of bloody stools. What labs would you assess and why?
HNH (looking for anemia) and platelet (looking for clotting issue)
Pt admitted to the med-surg floor with a laceration (cut) to his left thigh. He reports that he acquired the cut playing basketball but came to the hospital when he was not feeling well. The laceration continues to bleed despite pressure being applied to the site. What labs would you assess and why?
platelet
- sodium (Na)
- potassium (K)
- calcium (Ca)
- magnesium (Mg)
- chloride (Cl)
- bicarbonate (HCO3)
- phosphate (PO)
electrolytes