PHYSIOLOGICAL Flashcards by KENITH V. LAGO

refer to the process of emptying the urinary bladder

Micturition, voiding, and urination

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when does an adult feel urinating what amount?

250 and 450 mL of urine

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Urine output for infants

250 to 500 mL

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elimination system reaches maturity during this period.

SCHOOL-AGE CHILDREN

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excessive fluid intake, a
condition known as

polydipsia

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low urine output, usually less than 500 mL a day or 30 mL an hour for an adult.

Oliguria

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refers to a lack of
urine production.

Anuria

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a technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis.

dialysis

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is voiding at frequent intervals, that is, more
than four to six times per day

Urinary frequency

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is voiding two or more times at night.

Nocturia

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is the sudden, strong desire to void.

Urgency

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involuntary urination in children beyond the age when voluntary bladder control is normally acquired

Enuresis

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involuntary leakage of urine or loss of bladder control, is a health symptom, not a disease

Urinary incontinence (UI)

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Urine outputs below ____may indicate low blood volume or
kidney malfunction and must be reported.

30 mL/h

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in measuring fluid output how much time interval should u calculate and document

end of 24 h on the client’s chart

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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,

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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)

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the end product of protein metabolism, is measured as

blood urea nitrogen (BUN)

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a test uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate

creatinine clearance

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dysfunction in urine elimination (nanda label):

Impaired Urinary Elimination

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interventions in Maintaining Normal Urinary Elimination

promoting adequate fluid intake

maintaining normal voiding habits,

assisting with toileting

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requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable

Bladder retraining

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drug to stimulate bladder contraction and facilitate voiding.

bethanechol chloride

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manual pressure on the bladder to promote bladder emptying. This
is known as

Credé’s maneuver

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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)