PHYSIOLOGICAL Flashcards
refer to the process of emptying the urinary bladder
Micturition, voiding, and urination
when does an adult feel urinating what amount?
250 and 450 mL of urine
Urine output for infants
250 to 500 mL
elimination system reaches maturity during this period.
SCHOOL-AGE CHILDREN
excessive fluid intake, a
condition known as
polydipsia
low urine output, usually less than 500 mL a day or 30 mL an hour for an adult.
Oliguria
refers to a lack of
urine production.
Anuria
a technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis.
dialysis
is voiding at frequent intervals, that is, more
than four to six times per day
Urinary frequency
is voiding two or more times at night.
Nocturia
is the sudden, strong desire to void.
Urgency
involuntary urination in children beyond the age when voluntary bladder control is normally acquired
Enuresis
involuntary leakage of urine or loss of bladder control, is a health symptom, not a disease
Urinary incontinence (UI)
Urine outputs below ____may indicate low blood volume or
kidney malfunction and must be reported.
30 mL/h
in measuring fluid output how much time interval should u calculate and document
end of 24 h on the client’s chart
steps in measuring urine
- Apply clean gloves.
- Take the container to bedside.
- Place the container under the urine collection bag
- Open the spout and permit the urine
- Close the spout,
is measured to assess the amount of retained urine after voiding and determine the need for interventions
Postvoid residual (PVR)
(urine remaining in the bladder following voiding)
the end product of protein metabolism, is measured as
blood urea nitrogen (BUN)
a test uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate
creatinine clearance
dysfunction in urine elimination (nanda label):
Impaired Urinary Elimination
interventions in Maintaining Normal Urinary Elimination
promoting adequate fluid intake
maintaining normal voiding habits,
assisting with toileting
requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable
Bladder retraining
drug to stimulate bladder contraction and facilitate voiding.
bethanechol chloride
manual pressure on the bladder to promote bladder emptying. This
is known as
Credé’s maneuver
The client with a retention catheter should drink up to
3,000 mL/day
Routine changing of catheter and tubing is not recommended (t/f)
True
a flushing or washing-out with a specified solution.
irrigation
what is done when the bladder is left intact but voiding through the urethra is not possible
vesicostomy
the expulsion of feces from the anus and rectum.
Defecation
Healthy fecal elimination usually requires a daily fluid intake of
2,000 to 3,000 mL
are medications that stimulate bowel activity and so assist fecal elimina
tion.
Laxatives
a mass or collection of hardened feces in the
folds of the rectum.
Fecal impaction
diagnostic labels for fecal elimination problems
- Bowel Incontinence
- Constipation
- Risk for Constipation
- Perceived Constipation
- Diarrhea
- Dysfunctional Gastrointestinal Motility
interventions For Constipation
Increase daily fluid intake,
instruct the client
to drink hot liquids,
warm water with a squirt of fresh lemon,
fruit juices, especially prune juice
interventions for diarrhea
Encourage oral intake of fluids and bland food.
Eating small amounts
clients with flatuelence (intervention)
Limit carbonated beverages,
the use of drinking
straws, and chewing gum
is often used for the adult
client who can get out of bed but is unable to walk to the bathroom
commode
e drugs that induce defecation
Cathartics
herbal oils known to act as
agents that help expel gas from the stomach and intestines
Carminatives
A test to measure lung volume and capacity
Pulmonary function tests
diagnostic labels for clients with oxygenation problems:
Ineffective Airway Clearance: inability to clear secretions or obstructions
Impaired Gas Exchange : inspiration and/or expiration that does not provide adequate ventilation.
Activity Intolerance: insufficient physiological or psychological
energy to endure or complete required or desired daily activities.
nursing interventions to facilitate pulmonary ventilation
ensuring a patent airway, positioning, encouraging deep breathing and coughing, and ensuring adequate hydration.
, lung inflation techniques, administration of analgesics before deep breathing and coughing, postural drainage, and percussion and vibration
When coughing raises secretions high enough, the client may either
expectorate
are devices that add water vapor to inspired air.
Room humidifiers provide cool mist to room air
Humidifiers
are used to deliver humidity and medications
Nebulizers
is forceful striking of the skin with cupped hands
clapping
can mechanically dislodge tenacious secretions
from the bronchial walls
Percussion
To percuss a client’s chest, follow these steps:
- Cover the area to reduce discomfort.
- Ask the client to breathe slowly and deeply to promote relaxation.
- Alternately flex and extend the wrists rapidly to slap the chest
- Percuss each affected lung segment for 1 to 2 minutes
is the drainage by gravity of secretions from various lung segments
Postural drainage
is used for clients with excessive secretions such as cystic fibrosis, COPD, and bronchiectasis
mucus clearance device (MCD
can replace oxygen masks when masks are poorly tolerated by clients.
Face Tent
is placed through a surgically created tract
in the lower neck directly into the trachea.
Transtracheal Catheter
delivery of air or oxygen under pressure without the need for an invasive tubes
Noninvasive Positive Pressure Ventilation (NPPV
are inserted to maintain a patent air passage for
clients whose airways have become or may become obstructed.
Artificial Airways
s are used to keep the up
per air passages open when secretions or the tongue may obstruct them
Oropharyngeal and nasopharyngeal airways
are most commonly inserted in clients who have had general anesthetics or for those in emergency situations where mechanical ventilation is required
Endotracheal Tubes
is the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet
Suctioning
x is the accumulation of blood
in the pleural space
hemothorax
a recording of the heart’s electrical activity.
Cardiac monitoring
diagnostic labels for clients with circulation problems
- Decreased Cardiac Output: inadequate blood pumped by the
heart to meet metabolic (demands) of the body - Risk for Peripheral Neurovascular Dysfunction: vulnerable to dis
ruption in the circulation, sensation, and motion of an extremity,
which may compromise health - Activity Intolerance: insufficient physiological or psychological
energy to endure or complete required or desired daily activities.
When planning care the nurse identifies nursing interventions that
will assist the client to achieve these broad goals:
Maintain or improve tissue perfusion.
Maintain or restore an adequate cardiac output
NIC interventions related to decreased
cardiac output and tissue perfusion include the following:
- Circulatory Care: Arterial Insufficiency
- Cardiac Care
- Hemodynamic Regulation.
This is particularly important for clients with venous
provide frequent position changes
Encourage leg exercises
Avoid pillows under the knees or more than 15 degrees of knee
Vascular
Position the client in a high-Fowler’s position to decrease preload
and reduce pulmonary congestion.
* Monitor intake and output. Fluid restriction is usually not re
quired for clients with mild to moderate cardiac dysfunction.
With severe heart failure, a fluid restriction may be ordered
Cardiac
a combination of oral resuscitation (mouth-to-mouth breathing which supplies oxygen to the lungs, and external cardiac massage , which is cardiac function and blood circulation
Cardiopulmonary resuscitation (CPR)
a sodium deficit
Hyponatremia
The unit used to measure I&O is
milliliter (mL)
fluids need to be recorded:
Oral fluids-
Vomitus and liquid feces - amount and type of fluid and the time need to be specified
Tube drainage -gastric or intestinal drainage.
Wound and fistula drainage-
are performed to evaluate a client’s acid–base balance and oxygenation.
Arterial blood gases (ABGs)
s a measure of the solute concentration of blood.
Osmolality
are often prescribed for
clients with actual or potential fluid volume deficits arising,
Increased fluids (ordered as “push fluids”)
are used to increase the blood volume fol
lowing severe loss of blood
Volume expanders
These catheters frequently are used for long-term
IV access when the client will be managing IV therapy at home.
peripherally inserted central venous catheter (PICC)
