Fund 50 week 3 - day 1.2 - elimination Flashcards
Upper urinary system: (just amount per kg)
just ureter and Kidneys
Normal urine output: 0.5-1.5 mL/kg/hour.
women urethra - 2 inches
men - 6 - 8 inches
Lower urinary system
Bladder and urethra.
❖(he didn’t even discuss this #, don’t worry about it) Avg bladder 500 ml of urine in women and 700 ml in men.
function of kidneys(a wet bed p) (taking acid)
❖ A – Acid base balance (bicarbonate)
❖ W- Water balance
❖ E- Electrolyte balance via selective
reabsorption and excretion of electrolytes
and substances
❖ T –Toxin removal (Filters and excretes end
products of metabolic waste e.g. urea,
creatinine, ammonia, and uric acid)
❖ B- Blood pressure regulation via renin-
angiotensin system
❖ E- Stimulates Erythropoietin to produce
RBC
❖ D -Converts vitamin D on the skin to the
active form 1, 25- Vit D
❖ P – Protein regulation: albumin,
erythropoietin, and vitamin D-binding
protein.
❖ Neurogenic bladder
result of neurological condition
❖ Spinal cord injury, neurodegenerative d/o, cauda equina
Acute renal injury (AKI) (what drops, and what causes it - 2 things -either injuring it or blocking it)
❖ Acute drop in blood pressure
❖ Injury to the glomeruli or tubules
❖ Obstruction of kidney outflow leading to hydronephrosis
Chronic kidney disease (CKD) (diseases that cause it - diabetes is chronic)
❖ Slow loss kidney function over months and years
❖ Caused by HTN - high blood pressure, DM, glomerulonephritis, heart failure
ESRD - End Stage Renal Disease (what rises on blood test (what is always measured for kidneys), and what happens to ppl with ESRD?)
usually can’t make any urine
➢ chronic rise in serum creatinine leading renal failure
➢ requires life-long dialysis or renal transplant
diagnostic lab of renal function(comprehensive)
MOST important thing to remember is you need comprehensive tests to assess renal function
BUN Byproduct from protein catabolism.
Cleared by kidneys, Not specific to
renal function
8-25 mg/dl
Protein breakdown, dehydration,
overhydration, liver failure influence
value
Creatinine
Creatinine Byproduct of skeletal muscle cell
metabolism; evaluates nephron fcn
Men: 0.6-1.5 mg/dl
Women: 0.6-1.1
Creatinine clearance Indicates GFR Men
Creatinine clearance Indicates GFR Men: 95-135 ml/min
Women: 85-125 ml/min
GFR (what number is renal dysfunction)
GFR Identifies renal dysfunction > 60 ml/min. below 60 means kidney disease
chronic kidney injury main causes - (the 2 you know well)
Progressive, irreversible loss of
kidney function
▪ DM and HTN leading causes
▪ ESRD is when GFR < 15mL/min
(at least 90 ml/min)
▪ GFR measures kidney function
▪ Based on creatinine level, age,
body size, gender, ethnicity
Anuria (and when would you see this?)
Absence of urine production - End stage renal disease or sepsis
Oliguria (olga is small)
❖ Oliguria – Urine < 30mL/hr
❖ Etiologies: AKI, dehydration, enlarged prostate
❖ Polyuria (and what disorders)
Excessive urination
❖ May be associated with overhydration, DM, Diabetes
Insipidus, other kidney disease
❖ Dysuria (and what causes it)
Painful or difficult urination
❖ Assoc with infection or urine obstruction (kidney stones)
effects of aging (just loss of kidney function)
❖ Between ages 30 and 90
▪ Size and weight of kidneys ↓ by 20% to 30%
❖ By 7th decade
▪ Loss of 30% to 50% of glomerular function
❖ Atherosclerosis accelerates ↓ of renal size
effects of aging 2 (ability to do what with urine?)
Physiologic changes
▪ ↓renal blood flow → ↓GFR
▪ Altered hormonal levels
result in▪ ↓ability to concentrate urine
▪ Altered excretion of water, sodium, potassium, and acid
▪ Prostate enlargement
medications affecting urination
Nephrotoxic (capable of causing kidney damage)
❖ Diuretics: ↑ vol., frequency, urge incontinence
❖ Cholinergics stimulate bladder contraction
❖ Analgesics and sedatives impair CNS to control urination
❖ Anticoagulants may cause hematuria
❖ Some medications change the color of urine:
❖ Phenazopyridine (Pyridium): a urinary tract analgesic commonly used for UTI symptoms turns urine orange
❖ Amitriptyline and B-complex vit can turn urine green blue
❖ Levodopa for Parkinson can turn urine brown or black
urinary history assessment**(PAHML - the palm of my urine)
- Urinary Pattern (frequency, urgency, drippling, incontinence, inability to empty bladder)
- Appearance of Urine – color, odor, and clarity
- History of urinary problem- UTI, surgery, pain
- Current medications (many medications are nephrotoxic)
- Lifestyle Questions: how much fluid a day, smoker, caffeinated
drinks
urinary assessment
Person should be in dorsal recumbent position
Inspect:❖ Skin and mucosal membrane
❖ Skin turgor, oral mucosa for hydration status
❖ Perineum for incontinence related skin maceration
❖ Observe urethral orifice for discharge, lesions, inflammation
❖ Inspect urine output for color, clarity, odor
Palpate:❖ Normal bladder is positioned in the pelvic cavity around the symphysis pubis; not palpable when empty
❖ Bladder distended (palpable and well above symphysis pubis)Percuss:
❖ Costovertebral angle tenderness
❖ Formed by junction of 12th rib and the spine
❖ Tenderness may indicate pyelonephritis
Auscultate:❖ May hear renal artery bruit- turbulent blood flow through a narrowed artery
pathological urinary disorders (don’t need to know this)
❖ UTI
➢ Catheter-associated UTIs (CAUTI)
➢ Cystitis
➢ Pyelonephritis (infection of ureters and kidneys)
➢ Urethritis
❖ Benign Prostate Hypertrophy
(BPH)
➢ leads to incomplete emptying
and frequent urination
❖ Nocturnal enuresis
❖ Incontinence
❖ Renal calculi
alterations in urinary elimination: UTI
Lower UTI
S/S▪ Dysuria, frequency, urgency, burning, pyuria (white blood cells in urine)
▪ Older adults may initially p/w change in mental status ▪ May or may not have sx
Lab Urine analysis▪ + nitrite (nitrite forming bacteria)▪ ↑ in Leukocyte esterase Urine Cx▪ E. coli most common
**If untreated, infection can progress up to kidneys
Upper UTI/ Pyelonephritis
S/S
▪ Fever, chills, flank pain, n/v,
malaise, hematuria
▪ Urosepsis
Diagnostic
▪ UA C&S
▪ Blood cx
▪ CBC, lactate acid
▪ Creatinine and BUN level for AKI
collecting urine
Supplies:
• Sterile collection container
• Clamp
• Syringe
• Anti-septic swap
• Non-sterile gloves
Do not collect from foley bag
• Observe sterile technique
while collecting specimen
24 hour collection (to measure what? and detect what?)
Purpose:To detect abnormal renal disorders such as diabetic nephropathy, nephrotic syndrome, nephrolithiasis (kidney stone)
❖ UOP from a 24 hr period collected to see how much creatinine clears through the kidneys.
❖ Also done to measure amount of protein, hormones, minerals, and other chemical compounds in the urine
specimen collection***
• Ensure patient and all caregivers understand the importance of collecting all urine during the 24 hrs• Post sign in bathroom with start and end time and date of collection•
Have patient empty bladder and discard which will be the ”start time”• Put “ALL” UOP in 24hrs in the urine container (usually on ice)•
At the end of 24 hrs, have pt void again and place urine in container.
**If any urine gets discarded
bladder scanner***
Used to measure urinary retention or post void residual (PVR)
❖Bladder distention
❖May result from BPH (prostate problem) prostate CA, neurogenic bladder, after long period of foley catheter use
❖S/S include frequent voids with
uti prevention**
❖ Practice good personal hygiene
❖ **Always wipe from front to back
❖ Promote fluid intake (2000 to 2500mL/day)
❖ Empty bladder completely when you feel the urge (urinary stasis promotes bacterial growth)
❖ Wear moisture wicking underwear
❖ During sexual intercourse, use vaginal lubricants if needed (decreases vaginal friction and potential tear)
❖ Empty bladder after intercourse (flushes out bacteria that may have entered urethra)
❖ Change sanitary pads and tampons frequently during menstruation
CAUTI**
**80% of nosocomial UTI’s caused by urinary catheters (usually undetected and patient becomes septic)
❖Increases hospital stay, morbidity and mortality in patients
****Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems
**Bacteria with biofilms resistant to antimicrobials and host defenses
❖CAUTI rates often a benchmark measure in the National Healthcare Quality and Disparities Reports (NHQDR)
CAUTI prevention***(catheters) (CDC guidelines)
❖Insert catheters only for appropriate indications
consider external devices
**Remove catheter as soon as possible
**Normal and expected to feel burning sensation initially after catheter removal
❖Ensure sterile technique throughout insertion procedure
❖Proper hand hygiene and Standard Precautions
Nursing Management of Ileocdonuit (I guess this means stoma?)**(and monitor what?)
Inspect stoma regularly
❖Monitor UOP and PO intake for adequate hydration
❖Mucous threads in urine is normal since urinary diversion is created using intestinal tract
❖Encourage patient participation in care of stoma
❖Start education on care of urinary device early
➢ Assess coping and readiness for teaching
urinary incontenence (TOILETED) and the last weird one
Inability to control urine flow
Mnemonic for contributing factors: TOILETED
▪ T: Thin and dry vaginal and urethral epithelium
▪ O: Obstruction
▪ I: Infection
▪ L: Limited Mobility
▪ E: Emotional or psychological problems
▪ T: Therapeutic Medications
▪ E: Endocrine disorders (Diabetes Insipidus)
▪ D: Delirium
types of urinary incontenence
Transient
❖ Appears suddenly and last ≤ 6mths
❖ Etiologies: diuretics, acute delirium, acute illness
Stress
❖ Involuntary loss of urine r/t ↑ intrabdominal pressure e.g. coughing, sneezing, laughing, after childbirth
Overflow
❖ Involuntary urine loss r/t overdistention of bladder
Mixed
❖ Urine loss with features of ≥ 2 types of incontinence
Functional
❖ As a result of inability to reach toilet r/t physical, environmental barriers, memory loss, neurological
Total
❖ Continuous and unpredictable urine loss r/t anatomical abnormality
Nursing Management: Incontinence***
Nursing Management: Incontinence
❖Bladder training according to a timetable rather than urge to void
❖**Pelvic floor muscle training: Kegel
❖Regulate fluid intake during evening hours and encourage fluids between 6 am and 6 pm
❖Avoid ETOH and caffeinated beverages
❖Pharmacologic dependent on type of incontinence
❖Keep perineal area clean and dry (change incontinent pads when wet)
❖Take diuretics early in the day
❖Lose weight for BMI >30
Stomach (store the chyme in the stomach, and use the sphincter)
(GI Tract Role and Function)
❖ Stores food during eating, secretes digestive enzymes to partially break down food (chyme)
❖ Pyloric sphincter controls movement of chyme into small intestine
Bowel Elimination Control
Bowel Elimination Control
❖ Controlled by the autonomic nervous system
❖ Parasympathetic nervous system
➢ Rest and digest
➢ Stimulates intestinal peristalsis
❖ Internal anal sphincter is under involuntary
control
❖ External anal sphincter under voluntary control
❖ Valsalva maneuver: bearing down technique
during defecation→ ↑ intra-abdominal and
thoracic pressure → ↓blood flow to atria and
ventricles → Cardiac output → bradycardia and
syncope
Assessment of GI System*****
Assessment of GI System
Assessment order: Inspect, auscultate, percuss, palpate
Inspect:
❖ Moist pink lips, mucosal membrane, oral hygiene
❖ Cough, gag, dysphagia
❖ Contour, lesions, for visible peristaltic waves
❖ Anal fissures, hemorrhoids
Auscultate:
❖ Bowel sounds in all quadrants
Palpation:
❖ Use warm hands
❖ Palpate for tender areas
Percuss:
❖ General tympany is normal
Constipation:
(alternation in bowel elimination) (causes)
❖ Common: Narcotics/opioids
➢ Other meds: antihistamine, antiHTN, diuretics, Fe and Ca supplements
❖ Immobility, prolonged bedrest, lack of exercise
❖ Irregular bowel habits, ignoring urge to defecate
❖ Post-op → paralytic ileus
❖ Chronic illness
❖ Diet: Low fiber diet, high in animal fat- meat, dairy, eggs
❖ Inadequate fluid intake
❖ Older population: Loss of abdominal elasticity, slowed peristalsis, reduced intestinal mucus secretion, cognition impairment
preventing and treating constipation***(how much fluid and fiber)
Dietary: High fiber with adequate fluids
➢20-35 g fiber/day
➢Fluids 1.8 to 2.5L /day
➢Avoid caffeinated drinks
❖ Do not delay urge to defecate
(Results in hard stool, decrease urge)
***Exercise
❖ Medication: stool softeners, laxatives, enemas, suppositories, PO narcan, digital dis-impaction
fecal impaction*****
Prolonged retention of fecal material forming hard mass in rectum:
Signs and Symptoms:
❖ Constipation
❖ Bloating
❖ Bowel obstruction on KUB
❖ Involuntary leaking of liquid stool
❖ Nausea
❖ Excessive flatulence
Treatment for constipation/fecal impaction:
❖ Laxatives, Suppository and enemas
❖ Manual Removal
❖ Medications: narcan, cholinergics
preventing and Treating Diarrhea***
Definition of diarrhea is ≥ 3 loose stools in a 24hr period
Etiologies:
Excessive use of laxatives
Certain antibiotics
Infectious – Clostridium Difficile ***Initiate enteric contact isolation and send stool sample for C-diff
Complications:
Dehydration
Electrolyte abnormalities
Moisture associated skin damage (Incontinence Associated dermatitis
Infectious Diarrhea: Clostridium Difficile**
Etiology:
▪ Antibiotics (abx) kill off normal flora increasing
susceptibility to pathogenic organisms
▪ C-diff spores can survive many months on objects-
commodes, bedside tables, thermometers, etc.
▪ Must use soap and water for hand hygiene (Etoh base not effective)
▪ Enteric isolation in private room
▪ Do not give anti-diarrheals as the
diarrhea is infectious
▪ C. diff is treated with combo abx-Metronidazole and Vancomycin
▪ Fecal transplantation
▪ Test all patients for C-diff if having ≥
3 loose stools in 24 hr period
▪ Avoid giving unnecessary broad
spectrum abx
Nursing Management for Diarrhea***
Nursing Management for Diarrhea
❖Hydrate!
❖Antidiarrheal agents only if not infectious diarrhea
❖Clear liquid diet or as tolerated
❖BRAT diet
➢ Banana
➢ Rice
➢ Applesauce
➢ Toast
❖Reduce fiber
❖Limit caffeine
❖Yogurt and probiotics
Bowel Diversion Device**(stoma, diseases that would cause you to need one)
Indication:
❖ Severe IBS
❖ Severe Crohn’s
❖ Bowel perforation
❖ Colon or rectal CA
❖ Abd trauma
*May be permanent or temporary
bowel diversion - Ileostomy**(illeana was a fluid dancer)
End of ileum (small intestine) brought through opening to abd wall to form a stoma. liquid to semi-liquid
acute kidney injury***▪ Intrarenal-factors (dying from the inside out - intra)
causing direct damage to kidneys/ATN (acute tubular necrosis)
acute kidney injury***Postrenal-factors - this is just obstruction
causing mechanical obstruction to flow of urine
▪ Potentially reversible
▪ Older adults more vulnerable
Colostomy
Colostomy: One end of large intestine is brought out onto abdominal wall by the
construction of a stoma
**Characteristics of stoma
➢ pink/red normal (pale-anemia, maroon/purple-ischemia)
➢ Edema (severe d/t obstruction, allergic rxn, gastroenteritis)
➢ Bleeding (small amount normal d/t high vascularity
**stoma - Characteristics of drainage/stool - change how often?
depends on new or existing ostomy and location of ostomy
❖ Note amount and frequency
❖ Change ostomy bag every 3 days or policy (more frequent if needed)
❖ Physical and Psychological support
what are the leading causes of CKD? (chronic kidney disease) think kidneys…(Just 2)
DM and HTN (high blood pressure) are the leading causes of CKD
bowel diversion (stoma) ascending***(c in ascend is for c for colostomy, c for semi)
colostomy - large intestine. perforating diverticulum in lower colon. semi-liquid
bowel diversion (stoma) - transverse (sideways can go either way, so…)
colostomy - large intestine. perforating diverticulum in lower colon. semi-liquid to semiformed, possibly increased.
bowel diversion (stoma) - sigmoid (freud is large and formed)
colostomy - large intestine. formed.
Foods high in what impede bacterial growth?
Foods high in Vit C., prevents UTIs
how often to Perform foley care/peri care?
every shift
CAUTI consideration - devices
Consider external urinary collection devices
CAUTI - maintain open or closed drainage system?
closed
CAUTI - where to keep foley bag?
Maintain unobstructed urine flow - keep foley bag below level of bladder
GI tract - small intestines (parts of the small intestine, functions)
❖ Approximately 20ft x 1in
❖ 3 parts: Duodenum, ileum, jejunum
❖ For digestion and absorption of nutrients
❖ Secretes enzymes to digest proteins and carbohydrates
❖ Digestive juices from liver and pancreases enter the duodenum for digestion
GI tract - large intestines (how long, how much water absorbed)
❖ Approx. 5 ft x 1-3”
❖ For absorption of water and formation of feces
❖ 800-1000mL water gets absorbed daily
❖ Peristalsis move intestines to push waste into rectum
GI tract - rectum
❖ Holds stool until evacuation
❖ 5”x1” (1” of that is the anal canal)
is minor bleeding with stoma normal?
yes
is caffeine good for constipation?
no
groups at risk for fecal impaction
Population at risk:
❖ Immobile patients – e.g. spinal cord injury and older adults
❖ Post-op (opioid use, decrease activity, n/v, low appetite)
Infectious – Clostridium Difficile***what to do if you suspect it?
Initiate enteric contact isolation and
send stool sample for C-diff
3 major causes of AKI (before, middle, after)
pre-renal, intranrenal, and post-renal factors
prerenal factors that cause AKI (I HADD prerenal factors)
dehydration, diarrhea, heart failure, acute blood loss
intrarerenal factors that cause AKI (vancomyicin intra, within, the kidneys)
exposure to nephrotoxins, (vancomyocin it’s excreted through the kidneys and can damage them)
post-renal factors that cause AKI (post with stone) - post is literally physical - after your kidneys
kidney stone, back up in kidneys
any pain in 12th rib is caused by…
pylonephritis
if older patient is acting confused, it could be a…
UTI
use a bladder scanner if the patient has…
not voided during your shift. if scanner shows around 300 ml, it’s the cutoff
