Lecture 12 Flashcards
Urinary and Bowel Elimination
What is micturition?
The entire process of urinary elimination including the urinary and nervous systems
when the brain gives the bladder permission to empty, what happens?
Bladder contracts and urinary sphincter relaxes allowing the urine to empty
which kidney is higher than the other and why?
The left is higher than the right because of the anatomical position of the liver
Nephrons remove waste products from the blood and play a major role in the regulation of…
Fluid and electrolyte balance
what part of the kidney is the ureter attached to?
the renal pelvis
what is the normal range of urine production everyday?
1 to 2 L/day
How do the kidneys help regulate BP?
Via the renin-angiotensin system and the release of aldosterone and prostacyclin
The kidneys affect calcium and phosphate regulation by…
producing a substance that converts vitamin D into its active form
what are the two parts of the urinary bladder?
A fixed base called the trigone and a distensible body called the detrusor
is the release of urine voluntary or involuntary?
voluntary
how long is the male urethra?
about 18 to 20 cm (7 to 8 in.) long
how long is the female urethra?
about 3 to 4 cm (1 to 1.5in.) long
Why are females at increased risk for UTI?
close access to bacteria in the perineal area
what areas of the brain control urination(4)?
1) Cerebral cortex
2) Thalamus
3) Hypothalamus
4) Brainstem
There are two micturition centers in the spinal cord. What do they coordinate?
1) Inhibition of bladder contraction
2) Bladder contractility
What the bladder fills to approx. (BLANK) most people experience a strong urge to urinate.
400 - 600mL
when the time and place is appropriate, the brain sends a message to…
relax urinary sphincter and contract the bladder resulting in voiding
When the time and place is inappropriate, the brain sends a message to the micturition centers to…
contract the urinary sphincter and relax the urinary bladder (holding it)
children cannot voluntarily control voiding until…
18-24 months
readiness for toilet training includes the ability to:
1) Recognize the feeling of fullness
2) To hold urine for 1 - 2 hours
3) Communicate the sense of urgency
URINARY
Older adults may experience(4):
1) Decreased bladder capacity
2) Increased bladder irritability
3) Increased frequency of bladder contractions during bladder filling
4) Decreased ability to hold urine between initial desire to void and urgent need to void
Increased rate of urinary incontinence in older adults is due to(2):
1) Chronic illness
2) Factors that interfere with mobility, cognition, and manual dexterity
When it comes to privacy during voiding, what is acceptable among cultures?
Americans and many others expect bathrooms to be private while many other cultures accept communal toilet facilities
Apart from personal preference, what else can dictate who is acceptable to assist in elimination practices?
religious and cultural norms
social expectations (e.g. school recesses, work breaks) can interfere with timely (BLANK)
voiding
Anxiety can impact the bladder emptying due to:
inadequate relaxation of the pelvic floor muscles and urinary sphincter
Depression can decrease the desire for…
urinary continence
why does alcohol make you pee alot?
It decreases the release of antidiuretic hormones
caffeine and other bladder irritants can prompt unsolicited bladder contractions resulting in…(3)
1) Frequency
2) Urgency
3) Incontinence
Diabetes mellitus, multiple sclerosis, and stroke can alter bladder contractility and the ability to sense bladder filling. What will these patients experience(2)?
1) Bladder overactivity
2) Deficient bladder emptying
Some conditions can affect a patient’s ability to make it to the toilet on time. list 4.
1) Arthritis
2) Parkinson’s disease
3) Dementia
4) Chronic pain syndromes
Spinal cord injury or intervertebral disk disease above S-1 can cause(2):
1) Loss of bladder control
2) Impaired coordination between bladder contracting and urinary sphincter
Prostatic enlargement can cause
urinary retention
Trauma during abdominal or pelvic surgery sometimes obstructs urine flow. What does this require?
Indwelling urinary catheter
What can anesthetic agents do to the urinary system?
It can decrease bladder contractility and/or sensation of bladder fullness causing urinary retention
TRUE OF FALSE: Urine color can not change due to drugs
F. some drugs change the color of urine
What color does phernazopyridine or Pyridium change urine to?
What is it for?
Changes urine orange and it is used for bladder discomfort
What color does riboflavin and vitamin b2 change urine to?
Intense yellow
Diuretics can increase urine output by preventing…
reabsorption of water and certain electrolytes
what can Anticholinergics do to the urinary system?
Increase the risk of urinary retention by inhibiting bladder contractility
what side-effect can hypnotics and sedatives have on the urinary system?
they can reduce the ability for a patient to recognize and act upon the urge to void
a cystoscopy may lead to localized trauma of the urethra resulting in…
transient (1 to 2 days) dysuria and hematuria
What is dysuria?
pain while urinating
what is hematuria?
blood in urine
What are factors that influence urination(9)?
GSPPFPSMD
1) Growth and development
2) Sociocultural factors
3) Psychological factors
4) Personal habits
5) Fluid intake
6) Pathological conditions
7) Surgical procedures
8) Medications
9) Diagnostic examination
what are urinary tract infections characterized by?
characterized by location
what is the upper urinary tract?
kidneys and ureters
What is the lower urinary tract?
bladder and urethra
What is bacteriuria?
presence of bacteria in the urine
bladder infections should be treated with what?
antibiotics
infection of the bladder can lead to what(2)?
1) Pyelonephritis (upper urinary tract infection)
2) Bacteremia or Urosepsis (life-threatening bloodstream infection
what are UTIs typically caused by?
E. coli
what is PVR?
post-void-residual urine- incomplete emptying of bladder
How is PVR measured(2)?
1) Ultrasound
2) Straight catheterization
What are symptoms of an infection of the lower urinary tract(6)?
1) Dysuria
2) Cystitis
3) Frequency
4) Urgency
5) Suprapubic tenderness
6) Foul-smelling and cloudy urine
What is cystitis?
inflammation of the bladder
what is a CAUTI?
catheter associated urinary tract infection
How much will medicare and medicaid reimburse for a CAUTI?
They no longer pay for costs associated with CAUTIs
what are the common forms of Urinary incontinence (UI)(3)?
1) Urgency UI
2) Stress UI
3) Mixed UI
An overactive bladder is often accompanied by…(2)
1) Urinary frequency
2) Nocturia
what is a functional UI?
Urine loss due to inability to reach the toilet
What is multifactoral incontinence?
UI caused by multiple interacting risk factors
What is a cystectomy?
surgical removal of the bladder
if a cystectomy is performed on a patient, where is the stoma located?
a section of intestine is converted into a urine storage and a stoma is created on it (ureterostomy)
what are the two types of continent urinary diversions called(2)?
1) Continent urinary reservoir
2) Orthotopic neobladder
What is a nephrostomy?
Small tubes tunneled through the skin into the renal pelvis to allow urine diversion to containers strapped to legs
when is a nephrostomy used?
when ureters are obstructed it is used to drain urine
A health care provider may suspect that a patient is experiencing urinary retention when the patient has:
A. large amounts of voided cloudy urine.
B. pain in the suprapubic region.
C. spasms and difficulty during urination.
D. small amounts of urine voided two to three times per hour.
D
A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:
A. abnormal defecation.
B. constipation.
C. fecal impaction.
D. fecal incontinence.
B
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because:
A. the presence of food stimulates peristalsis.
B. mass colonic peristalsis occurs at this time.
C. irregularity helps to develop a habitual pattern.
D. neglecting the urge to defecate can cause diarrhea.
B
what kind of infection control is used during perineal care or exam of genetalia?
medical asepsis
When your patient asks for help with a private or personal activity, it can be perceived as…(3)
1) Embarrassing
2) Being treated like a child
3) May threaten a patient’s self-determination
Things to assess while assessing a patient’s level of continence(3):
1) patient’s understanding of problem and their expectations of treatment
2) Patient’s ability to perform necessary behaviors associated with voiding or excreting
3) Patient’s expectations of what the nurse will do and what they can do independently
The nursing history (Urinary) includes a review of the patient’s(3):
1) elimination patterns
2) symptoms of urinary alterations
3) assessment of factors affecting the ability to urinate
When assessing the patient (Urinary) ask about daily voiding patterns including(4):
1) frequency
2) times of day
3) normal volume
4) recent changes
how many times per day does most people void?
5 or more times per day
information about the patient’s pattern of urination helps…
establish a baseline for comparison
what is Oliguria?
decreased urine output
what is polyuria?
excessive urination
How do you assess for kidney tenderness?
Percussing - gently percuss the costovertebral angle (angle formed by the spine and the 12th rib)
Auscultation - can detect the presence of renal artery bruit (sound resulting from turbulent blood flow through narrow artery)
How do you locate the bladder?
Percussion - used to identify a bull bladder - gently tap abdomen along the midline starting just above umbillicus - when sound changes to dull you have found bladder
what is involved with a urinary physical assessment(5)?
1) kidneys
2) bladder
3) external genitalia and urethral meatus
4) perineal skin
5) fluid intake, patterns, and amounts
Impaired urinary elimination
Functional urinary incontinence
Stress urinary incontinence
Urinary incontinence
Impaired urination
Urinary retention
what are these?
Nursing Clinical Problems
Prioritize:
* Patient’s immediate physical and safety needs
* Patient expectations and readiness to perform some self-care activities
Correct as is
If overfull bladder is suspected…
Further assessment with a bladder scanner is recommended if available
what are signs of urethral inflammation and and infection(3)?
1) Discharge
2) Lesions
3) Inflammation
what is often the goal (outcome) set by nurses concerning elimination?
Normal Urinary Elimination
Continence nurse specialists assist the patient in learning(3):
1) To inhibit urinary urge
2) Strengthen pelvic floor muscles
3) Fluid and food mods
when it comes to continence, Occupational therapists assist the patient in learning:
Efficient and safe toilet transfers
When it comes to continence, the Physical therapist help the patient with:
Strengthening exercises of the lower extremities
when it comes to continence, social workers facilitate:
Obtaining assistive devices in the home that are covered by insurance
Although patients often need to learn about all aspects of healthy urinary elimination…
its best to focus on a specific elimination process first and incorporate teaching as you provide care
to provide addition patient privacy, a nurse can mask the sound of urination by…
running the water in the sink
avoid the use of incontinence containment products unless…
unless needed for uncontrolled urine leakage
what can help decrease bladder irritability?
adequate fluid intake will help flush out solutes that collect in the urinary system and decrease bladder irritability
If patient needs to increase fluid intake what should the nurse do(4)?
1) Set a schedule for drinking extra fluids
2) Identify fluid preferences
3) Increase high fluid foods such as fruits
4) Encourage fluid intake in small volumes frequently
What can a patient do to help prevent nocturia?
Avoid drinking fluids 2 hours prior to bedtime
what is a strategy to stimulate bladder contractions?
help patients assume the normal position for voiding (women sitting men standing)
as a nurse how can you help your patient improve bladder emptying(2)?
1) encourage patients to wait until the urine flow stops completely and then encourage them to attempt a second void (double voiding)
2) encourage timed voiding
what is timed voiding?
voiding according to the clock and not the urge to void
what is the Crede method and when should it be implemented?
use hands to press against the bladder to assist in voiding (manual compression) and it should not be implemented unless you consult the HCP first
Some key nursing intervention that can help avoid a UTI are(3):
1) Promoting adequate fluid intake
2) Perineal hygiene
3) Facilitating regular voiding intervals
what are the different methods of nursing health promotion regarding the urinary system(4)?
1) Patient education
2) Promoting normal micturition
3) Promoting complete bladder emptying
4) Preventing infection
Nurses can promote normal micturition by helping the patient to(2):
1) Maintain elimination habits
2) Maintain adequate fluid intake
what are the various forms of continuing and restorative care associated with the urinary system(5)?
1) Lifestyle changes
2) Pelvic floor muscle training
3) Bladder retraining
4) Toileting schedules
5) Intermittent catheterization
what are the first-line techniques that are treatments for stress, urge, and urinary incontinence(4)?
Known as behavioral therapy which includes:
1) Lifestyle changes
2) Pelvic floor muscle training (PFMT)
3) Bladder retraining
4) A variety of toileting schedules
In some cases, patients and caregivers are taught to intermittently catheterize. When?
When the bladder does not empty
to avoid nocturia, patients with edema can…
elevate their legs in the afternoon for a few hours
what are some foods and fluids to avoid to reduce bladder irritation and decrease symptoms such as frequency, urgency, and incontinence(4)?
1) Artificial sweeteners
2) Spicy foods
3) Citrus products
4) Caffeine
what are kegals?
Pelvic floor muscle training (PFMT)
How are patients taught to inhibit the urge to void?
taking slow and deep breaths to relax, perform 5-6 strong pelvic muscle exercises (flicks) in quick succession, then distracting attention from bladder sensations. (This is bladder retraining)
when should patients who inhibit the urge to void start their trip to the bathroom?
after they have reduced or eliminated the strong urge to void
A bladder diary is used to identify voiding patterns and toileting is planned based on their pattern. what is this?
Scheduled toileting
what is prompted voiding?
a version of scheduled toileting used for those who are mildly or moderately cognitively impaired
the goal for intermittent catheterization is drainage of…
400mL of urine
what are the key components of incontinence-associated dermatitis prevention and treatment(3)?
1) Gentle skin cleansing w/ no rinse PH balanced cleanser
2) Skin moisturizer
3) Application of a moisture barrier product
if a topical fungal infection is developed as a result of incontinence, what is the treatment required?
Steroid/antifungal cream or ointment
what is chewed up food traveling to the stomach called?
a bolus
the stomach performs three tasks, what are they(3)?
1) A storage container for food and liquid
2) Mixes food with digestive juices into a substance called chyme
3) regulates the emptying of its contents into the small intestine
The sphincter between the stomach and esophagus does what?
Prevents reflux of stomach contents back into the esophagus
reabsorption in the small intestine is so efficient that by the time chyme reaches the end of the small intestine…
its a thick liquid with semisolid particles
what are the three parts of the small intestine(3)?
- Duodenum
- Jejunum
- Ileum
what are the parts of the large intestine(5)?
- ascending colon
- transverse colon
- descending colon
- sigmoid colon
5) rectum
what are the three functions of the colon(3)?
- Absorption
- Secretion
- Elimination
what pushes food through the colon?
Mass peristalsis
How many times does mass peristalsis occur?
3-4 times per day
when are the strongest mass peristalsis events?
about 1 hour after mealtime
each fold in the large intestine contains veins that become distended from pressure during straining. what does this distention result in?
hemorrhoid formation
what does straining while having a bowel movement indicate?
patient may need a diet or fluid change or there could be an underlying GI disorder
What are the factors that affect bowel habits(12)?
AFPPPMDPPPSD
1) Age
2) Fluid intake
3) Psychological factors
4) Position during defecation
5) Pregnancy
6) Medications
7) Diet
8) Physical activity
9) Personal habits
10) Pain
11) Surgery and anesthesia
12) Diagnostic tests
what are the differences of an infants digestive system(3)?
1) Smaller stomach capacity
2) Less secretion of digestive enzymes
3) More rapid intestinal peristalsis
When do children gain the ability to control defecation?
2 or 3 years old
What are the changes in adolescent’s digestive tract(2)?
1) Rapid growth of the large intestine
2) Increased secretion of gastric acids
Describe changes of the digestive tract in older adults(5):
1) May have decreased chewing ability
2) Peristalsis declines
3) esophageal emptying slows
4) absorption by the intestinal mucosa is impaired
5) anal sphincter weakens (Can lead to incontinence)
Fiber in diet provides the bulk in the fecal material. bulk-forming foods help:
Remove fats and waste products from the body
some foods may produce gas which…
distends the intestinal walls and increase colonic mobility
what is the recommended fluid intake for men and women?
men: 3L/day
women: 2.2L/day
what effect does physical activity have on peristalsis?
promotes peristalsis
what effect does stress have on the digestive system?
accelerated digestive process and increased peristalsis
when people resists the urge to defecate, what can happen?
constipation
if a patient needs to defecate in a bedpan what should you do?
raise the head of the bed to help them into a sitting position
A number of conditions such as hemorrhoids, rectal surgery, anal fissures (which are painful linear splits in the perianal area), and abdominal surgery result in discomfort. In these instances, the patient often suppresses the urge to defecate to avoid pain. what can happen to them when they do that?
constipation
why do pregnant women often get constipated and develop hemorrhoids?
the growing fetus obstructs the passage of feces and peristalsis slows during the third trimester. Straining during constipation can cause hemorrhoids to develop
what type of anesthesia affects the digestive tract and how?
general anesthesia causes temporary cessation of peristalsis
what is ileus and how long does it last?
a surgery where manipulation of the bowels causes peristalsis to cease. usually lasts for 24-48 hours
does local anesthesia affect the bowels?
minimally or not at all
what kinds of meds promote defecation?
laxatives
what kind of meds control diarrhea?
Cathartics
can a patient eat or drink before endoscopy, colonoscopy, or other testing that requires visualization of the GI tract?
no, patient cannot eat or drink for several hours before and enemas or laxatives are used to ensure intestines will be visible
constipation is commonly caused by(5):
1) improper diet
2) reduced fluid intake
3) lack of exercise
4) certain medications
5) repeated resistance to urge
What are common bowel elimination problems(6)?
CDFIIH
1) constipation
2) diarrhea
3) flatulence
4) impaction
5) incontinence
6) hemorrhoids
what can excessive diarrhea do to patient?
cause excessive loss of fluids leading to dehydration
Hemorrhoids are caused by increased venous pressure from(4):
1) Straining
2) Pregnancy
3) Heart failure
4) Chronic liver disease
describe the consistency of ileostomy and the various colostomies
liquid consistancy near the ileum or beginning of the colon and becoming more and more formed as you reach the end
Describe stool that leaves an ileostomy
fecal effluent leaves body before it enters colon (frequent liquid stools)
describe stool that leaves a sigmoid colostomy
more solid and formed stool
describe stool that leaves a transverse colostomy
thick liquid to soft consistency
why are stomas placed in the colon and ileum(2)?
1) temporary diversion of stool from an area of trauma or perianal wounds
2) may also be used to be a palliative diversion if a tumor is present or a colectomy is performed
what happens to the distal portion of the intestine that is cut to create a stoma?
it is either surgically removed or left in the abdominal cavity
are end ostomies permanent or reversible?
it could be either or. the rectum may be left in place or removed
what are the different stomas that can be created in the ileum or colon(5)?
1) sigmoid colostomy
2) transverse colostomy
3) ileostomy
4) Loop colostomy
5) End colostomy
a nursing history associated with the digestive system includes:
Bowel patterns and habits
What are the assessment factors involved with the digestive system(14)?
1) Elimination pattern
2) surgery or illness
3) Stool characteristics
4) Medications
5) Routines
6) Emotional state
7) Bowel diversions
8) Exercise
9) Appetite changes
10) Pain or discomfort
11) Diet history
12) Social history
13) Daily fluid intake
14) Mobility and dexterity
Assessing usual bowel elimination patterns includes:
Frequency and time of day
Assessing the patients description of stool characteristics includes determining if the stool is(3):
1) watery or formed
2) soft or hard
3) what color it is
how do you get objective data of stool characteristics?
use a scale such as the bristol stool form scale
Assessment of the routines followed to promote bowel elimination includes things like(4):
1) drinking hot liquids
2) eating specific foods
3) taking time to defecate during a certain time of the day
4) use of laxatives, enemas, or bulk-forming additives
Assessing presence and status of bowel diversions includes(7):
1) determining presence of stoma
2) frequency of emptying stoma pouch
3) character of feces
4) appearance and condition of stoma
5) condition of peristomal skin
6) type of pouching system device used
7) methods to maintain the function of the ostomy
Assessing changes in appetite includes(2):
1) changes in eating patterns
2) weight loss or gain (if weight was lost or gained assess whether it was intentional or not
Why do we assess emotional state during an assessment associated with the digestive function?
emotional state can alter frequency and defecation. stress can cause changes in bowel movements
why do we assess for abdominal pain in an assessment associated with digestive function?
the type, frequency, and location of abdominal pain can help identify the source of the problem
what are symptoms of a bowel obstruction(3)?
1) cramping pain
2) nausea
3) absence of bowel movements
assessing social history for a digestive related assessment includes:
whether they share their living quarters with others, how many bathrooms there are. whether they are able to ambulate on their own. these factors can affect access to the restroom
why do we assess mobility and dexterity in an assessment related to the digestive system?
to determine if they need assistive devices or help from personnel
what is type 1 stool?
separate hard lumps like nuts (difficult to pass)
what is type 2 stool?
lumpy and sausage like, mild constipation
what is type 3 stool?
A sausage shape with cracks in the surface; normal
what is type 4 stool?
Like a smooth, soft sausage or snake; normal
what is type 5 stool?
Soft blobs with clear-cut edges (passed easily)
what is type 6 stool?
fluffy pieces with ragged edges, mushy
what is type 7 stool?
watery, no solid pieces (entirely liquid)
What are these?
Impaired bowel elimination
Bowel incontinence
Constipation
Perceived constipation
Risk for constipation
Diarrhea
Nursing Clinical Problems that apply to patients with elimination problems
What are these?
*Patient establishes a regular defecation schedule.
*Patient is able to list proper fluid and food intake needed to soften stool and promote regular bowel elimination.
*Patient implements a regular exercise program.
*Patient reports daily passage of soft, formed brown stool.
*Patient does not report straining or discomfort associated with defecation.
Nursing Outcomes (Goals)
What are continuing and restorative care provided to patients suffering bowel elimination issues(5)?
1) Bowel training
2) Maintenance of proper fluid and food intake
3) Promotion of regular exercise
4) Management of the patient with fecal incontinence or diarrhea
5) Maintenance of skin integrity
what is bowel training and who can benefit from it?
setting a time to defecate each day and using measures that promote defecation. patients with incontinence secondary to cognitive impairment can benefit from it
what types of foods promotes normal elimination(3)?
1) whole grains
2) legumes
3) fresh fruits and vegetables
what kinds of foods are recommended for patients with diarrhea(5)?
low residue foods such as:
1) white rice
2) potatoes
3) bread
4) bananas
5) cooked cereals
when increasing fiber it is important to…
drink enough fluids
what happens to stool if you increase fiber without increasing fluid intake?
it creates hard poop
a patient with diarrhea, fecal incontinence, or an ileostomy is at risk for skin breakdown. why(2)?
1) liquid stook contains digestive enzymes that cause rapid breakdown of the skin
2) skin further irritated with repeated wiping with toilet paper or frequent ileostomy pouch changes
Ask these questions when expected outcomes concerning bowel elimination have not been met(3):
*Do you use medications such as laxatives or enemas to help you defecate? How often?
*What barriers are preventing you from eating a diet high in fiber and participating in regular exercise?
*How much fluid do you drink in a typical day? What types of fluids do you normally drink?
