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Med-Surge > Potter & Perry cp 43- Urinary elimination > Flashcards

Potter & Perry cp 43- Urinary elimination Flashcards

1
Q

urinary tract infections (risk factors)

A

-can cause cystitis, urethritis, and in males, prostatitis
-risk factors for UTI in women include: sexual activity, pregnancy, diaphragm, or spermicide use and low vaginal estrogen level in postmenopausal women
other causes- obstruction of the urinary tract (benign prostatic hyperplasia in men) or (pelvic organ prolapse in women), incomplete bladder emptying, and abnormal anatomy
-elders
-pts using antibiotics
-pts w/ decreased immunity

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2
Q

urinary tract infection manifestations

A

-burning sensation during urination (dysuria)
-fever
-chills
pain
-nausea and vomiting
-malaise may develop if the infection worsens
inflammation of the bladder (cystitis)
-urgent senstation to void
-cloudy, foul smelling urine
-change in urine color
if infection spreads to the upper urinary tract the kidneys causing pyelonephritis, rapid onset of flank or lower back pain, tenderness, fevers, and chills can occur

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3
Q

complications of UTI

A
  • can spread to the upper tract, causing kidney infection (pyelonephritis) and possible long term kidney damage
  • bacteria can also spread to the bloodstream (bactermia) leading to urosepsis
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4
Q

asymptomatic bacteriuria

A

presence of bacteria but no symptoms of UTI and should not be treated with antibiotics

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5
Q

which is the most common organism associated with CAUTI (catheter associated UTI)

A

escherichia coil

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6
Q

urinary incontinence

A

any involuntary loss of urine

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7
Q

what do we worry most when it comes to urine incontinence?

A

-creates potential for skin breakdown esp for immobilized pt become high risk for pressure injuries

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8
Q

(OAB) overactive bladder syndrome

A

includes bladder urgency, often w/ increased frequency and nocturne and may or may not include urgency UI
OAB occurs in the absence of obvious pathology or UTI

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9
Q

indications for in-dwelling urinary catheter (short-term

A

-Select surgical procedures/postoperative care (e.g., urological surgery, prolonged surgery)
-Accurate monitoring of urine output every 1–2 hours in critically ill patients
-Prolonged immobilization due to trauma • Acute urinary retention or bladder
obstruction
-Instillation of medications into the bladder • End-of-life care only if required for comfort

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10
Q

indications for insertion of an in-dwelling catheter (long term >14 days)

A
  • Bladder outlet obstruction pending surgery or if the patient is not suitable for surgical intervention
  • Chronic retention related to neurological disease if intermittent catheterization is not feasible
  • Stage 3 or 4 sacral pressure injury or perineal skin breakdown in incontinent patients
  • Intractable urinary incontinence if alternate approaches have been tried but not successfu
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11
Q

nocturia

A

waking from sleep one or more times to void and has been associated w/ increased mortality
-seen in conditions such as OAB, prostate enlargement, excess urine production associated w/ peripheral edema in heart failure, obstructive sleep apnea, diuretics,

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12
Q

assessment of urinary system

A
  • evaluation of urinary tract symptoms
  • post-void-residual urine
  • bladder diary w/in 24 hr (time/volume of each void)
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13
Q

treatment options for nocturia

A
  • reducing fluid in the evening (2 hrs before bed)
  • elevating the feet for 1-2 hours before bedtime -to encourage return of fluid from the lower extremities
  • medications to reduce the volume or urine produced overnight
  • meds to relax the bladder muscles
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14
Q

micturition syncope

A

a type of situational syncope that is a reflex mediated and triggered by micturition and defecation, leading to a slow heart rate and hypotension resulting in transient loss of consciousness.
-educate pt to sit during void, and not to stand up suddenly

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15
Q

urinary retention

A

marked as the accumulation of urine in the bladder as a result of the bladder’s inability to empty

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16
Q

transient urinary incontinence risk factors/causes

A

“disappear”

  • Delirium
  • Intake of fluids
  • Stool impaction
  • Atrophic vaginitis
  • Psychological problems (depression)
  • Pharmaceuticals
  • Excess urine output
  • Abnormal lab values (e.g., hyperglycemia) • Restricted mobility
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17
Q

urgency UI

A

urine loss associated w/ immediately preceded by a sudden and urgent need to void that cannot be postponed. can be part of OAB syndrome

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18
Q

stress UI

A

urine loss resulting from increase intra-abdominal pressure (coughing, sneezing, laughing, lifting)

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19
Q

mixed UI

A

urine loss that has features of stress and urge incontinence

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20
Q

UI associated w/ chronic retention of urine (previously overflow UI)

A

involuntary loss of urine when the bladder does not completely empty w/ a high residual urine volume or a palpable nonpainful bladder remaining after voiding

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21
Q

functional UI

A

urine loss d/t inability to reach the toilet

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22
Q

multifactorial UI

A

urine loss d/t multiple interacting factors both inside and outside the urinary tract

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23
Q

sings of urinary retention

A
  • absence of urine output over several hours
  • bladder distension
  • restlessness
  • diaphoresis
  • moderate-to-extreme abdominal discomfort
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24
Q

how much can the bladder hold normally?

A

400-600mL

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25
Q

urinary diversion

A

a stoma to divert the flow of urine from the kidney directly to the abdominal surface is create for reason such as cancer, trauma, radiation injury to the bladder, fistulas, and chronic cystitis

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26
Q

what is an ileal loop or conduit

A

involves separating a loop of intestinal ileum w/ its blood supply intact. the utterers are implanted into the isolated segment of ileum, when remaining ileum reconnected. the isolated
ileal segment can then be used as a conduit for continuous urine drainage or fashioned into a continent reservoir
-ontinent pouch provides urinary storage in a leak-proof pouch. A portion connected to the abdominal wall acts as a continent nipple, and intermittent catheterization is therefore needed for emptying

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27
Q

disadvantage of an ileal conduit

A

is that if urine outflow becomes obstructed, irreversible damage to the kidneys can occur secondary to chronic infections or hydronephrosis

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28
Q

ureterostomy

A

bringing the end of one or both ureters to the abdominal surface
-in some cases a tube may need to be placed directly into the renal pelvis to provide urinary drainage. this procedure is called a nephrostomy

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29
Q

what do you want to watch out for urinary stomas?

A

-unprotected skin that comes in contact with urine will quickly become macerated and break down, causing pain, infection, increased hospital stays, and potential breakdown of the stoma

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30
Q

peritoneal dialysis

A

is an indirect method of cleaning the blood of waste products and excess fluid using osmosis and diffusion. The peritoneum functions as a semipermeable membrane for the procedure. A sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via a surgically placed catheter. The dialysate is left in the cavity for a prescribed time interval and then drained out by gravity

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31
Q

hemodialysis

A

involves using a machine equipped with a semipermeable filtering membrane (artificial kidney) that removes accumulated waste products and excess fluids from the blood.

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32
Q

how much does an adult normally void?

A

1500-1600 mL of urine daily or approx 500mL every 4h

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33
Q

what is PVRs- postvoid residual

A

volume remaining in the bladder after a void

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34
Q

common causes for hospital-acquired UTI

A
  • r/t poor hand hygiene
  • improper catheter care
  • faulty catherization technique
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35
Q

what is flank pain?

A
  • flank pain usually develops if the kidneys become infected or inflamed
    nurse can assess for flank tenderness early in the disease by percussing the costovertebral angle (the angle formed by the spine and the twelfth rib). Auscultation is also performed to detect the presence of a renal artery bruit (sound resulting from tur- bulent blood flow through a narrowed artery)
36
Q

dysuria

A

painful or difficult urination

37
Q

frequency urination

A

voiding more than eight times in 24 hours

38
Q

hesitancy void

A

difficulty initiating urination

39
Q

polyuria

A

voiding large amounts of urine

40
Q

oliguria

A

diminish urinary output relative to intake (usually 400mL in 24 hrs)

41
Q

dribbling

A

leakage of urine despite voluntary control of urination

42
Q

hematuria

A

blood in the urine

43
Q

how to assess for pelvic floor muscle in men?

A

pelvic floor muscle strength can be digitally assessed in men by gently inserting a gloved finger into the rectum and asking the patient to squeeze around it.

44
Q

how to assess the pelvic floor muscle in women?

A

pelvic floor muscle strength can be digitally assessed in women by gently inserting a gloved finger into the vagina. The examiner asks the patient to squeeze around the finger as firmly as possible, and then hold the contraction for up to 10 seconds

45
Q

report extreme increase or decrease in urine volume

A

an hourly output of less than 30 mL for more than 2 hours is cause for concern. Similarly, consistently high volumes of urine (polyuria), over 2 000 to 2 500 mL daily, should be reported to a physician

46
Q

normal characteristics of urine (colour)

A

Normal urine ranges from a pale, straw colour to amber, depending on its concentration. Urine is usually more concentrated in the morning or with fluid-volume deficits

47
Q

collecting a midstream (clean-voided) urine specimen

A
  • provide fluids 30 mins before urine collection
  • give pt soap, washcloth and towel to clean perineal area
  • clean from the urethral orifice to the back (left, right, then centre)
  • for men use circular motion and antiseptic swab to clean
  • initiate a stream, once stream is achieve, collect 30-60mL of fluid
  • remove specimen container before flow of urine stops and before releasing labia/penis
  • for men if foreskin was retracted, it must be replaced over the glans- if not swelling/constriction may occur cause pain and possible obstruction of urine flow
  • transport specimen to lab w/in 15-30 mins or refrigerate immediately (b/c bacteria grows quickly in urine)
48
Q

why do initiate a stream before collecting a urine specimen? (mid-stream void)

A

Initial stream flushes out microorganisms that accumulate at the urethral meatus and prevents transfer into specimen

49
Q

urine an pH

A

pH (4.6–8.0, average 6.0)
-urine that stands for several hours becomes alkaline
an acid pH helps protect against bacterial growth

50
Q

protein in the urine (none or up to 8 mg/100 mL)

A

not usually present

-it is seen in renal disease b/c damage to glomeruli or tubules allow protein to enter the urine

51
Q

glucose

A

Diabetic patients have glucose in their urine as a result of the inability of tubules to reabsorb high glucose concentrations (180 mg/100 mL). Ingestion of high concentrations of glucose may cause some glucose to appear in the urine of healthy people

52
Q

ketones in the urine

A

Patients whose diabetes mellitus is poorly controlled experience breakdown of fatty acids. Ketones are end products of fat metabolism. Patients with dehydration, starvation, or excessive aspirin usage also may have ketonuria

53
Q

blood in the urine (up to two red blood cells)

A

Damage to glomeruli or tubules may allow RBCs to enter the urine. Trauma, disease, or surgery of the lower urinary tract also may cause blood to be present
-may also be a women’s period-always check for this

54
Q

specific gravity (1.010–1.025)

A

Specific gravity measures concentration of particles in urine. High specific gravity reflects concentrated urine, and low specific gravity reflects diluted urine. Dehydration, reduced renal blood flow, and increased antidiuretic hormone (ADH) secretion elevate specific gravity. Overhydration, early renal disease, and inadequate ADH secretion reduce specific gravity.

55
Q

white blood cells in urine (0-4per low-power field)

A

indicates UTI the more presence of WBC

56
Q

bacteria in urine

A

may indicate UTI. pt may or may not have symptoms

57
Q

how to stimulate a void as a nurse?

A
  • sound of running water
  • stroking the inner thigh may stimulate sensory nerves and promote micturition reflex
  • you can also pour warm water of the pt’s perineum to create the urge to urinate
  • educate pt on maintaining adequate fluid intake 1500 to 2000mL promotes continence b/c concentrated urine irritates the bladder mucosa
  • have them listen to music or read a book
58
Q

what can worsen lower urinary tract symptoms

A

-tobacco (smoker’s cough aggravates stress incontinence)
-alcohol (acts as a diuretic) caffeine coffee, tea, and chocolate increases frequency
carbonate beverages
artificial sweetness (aspartame)
-constipation b/c it compresses the urethra and impede emptying (high fibre diet)
-dehydration d/t concentrated urine can irritate the bladder

59
Q

how often should a pt void?

A

approx every 3-4 hours to maintain normal bladder capacity (400-500mL)

60
Q

normal PVR

A

50mL

Those with consistently elevated PVRs (>100 mL) may require intermittent catheterization

61
Q

when do you asses the PVR? &considerations of PVR

A

10 minutes after the pts void
-set the gender designation per manufacture guidelines- women who have had a hysterectomy should be designated as a male
Palpate the patient’s symphysis pubis (pubic bone). Apply a generous
amount of ultrasound gel (or, if available, a bladder scan gel pad) to the midline abdomen 2.5 to 4 cm (1 to 1.5 inches) above the symphysis pubis. The ultrasound gel ensures adequate transmission and thus accurate measurement.

62
Q

catheterization of the bladder

A

-involves introducing a narrow tube through the urethra and into the bladder to allow in persons/ with spinal cord injury or spinal bifida

63
Q

intermittent catherization

A
  • a single-use straight catheter
  • introduced in the urethra for 5-10 minutes, just long enough to drain the bladder
  • straight catheter has a single lumen, w/ a small opening about 1.3 cm from the tip
  • urine drains from the tip, through the lumen, and into the receptacle
  • common in pts who have incomplete bladder emptying d/t neurogenic conditions (spinally cord injury)
  • catheters are washed w/ soaps and water, and left to air dry until next use
  • can be used to collect a sterile urine specimen but only in those who are unable to provide a midstream specimen
64
Q

coude catheter

A

type of catheter that has a curved tip and is used in male pt w/ enlarge prostate that partly obstructs the urethra
- it is less traumatic during insertion b/c it is stiffer and easier to control than the straight-tip catheter

65
Q

in-dwelling or Foley catheter

A
  • is retained for longer periods in the bladder by means of a small ballon that anchors it against the bladder neck
  • a blocked catheter should be changed ASAP
  • can either be two lumen or three lumen
66
Q

two lumen catheter

A

one lumen drains urine and the other carries sterile water to inflate or deflate the ballon

67
Q

three-lumen catheter

A
  • one lumen allows for irrigation

- is used for continuous bladder irrigation

68
Q

closed drainage system

A

after inserting an in-dwelling catheter, the nurse needs to maintain a closed urinary drainage system to minimize the risk of infection

69
Q

considerations for when pt has a urinary bag

A
  • the bag can hold up to 1000 -1500mL of urine
  • bag should never be raised above the level of the pt’s bladder
  • bag should hang on the bed frame or wheelchair w/out touching the floor
  • urine in the bag/tubing can become a medium for bacteria, and infection is likely to develop if urine flows back into the bladder
  • bag should never be hung on the side rails b/c it can be accidentally be raised above the level of the bladder
  • when pt ambulates, the drainage bag must be held below the pts waist
  • if catheter must be disconnected from the drainage tubing, both tips should be cleaned w/ an alcohol swab before being reconnected to minimize the transfer of microorganisms into the tubing
70
Q

urinary bag- spigot

A

it is at the base of the bag and is used to empty the bag

  • should always be clamped expect during emptying, and tucked into the protective pouch on the side of the bag
  • to ensure that the drainage system remains obstructed the nurse should check for kinks or bends in the tubing, avoid positioning the pt on the drainage tubing, and observe for clots or sediment that may occlude the collecting tubing
71
Q

considerations for inserting a straight intermittent catheter

A
  • assess intake/output
  • assess bowel- abdominal distention? obstruction? (prevents passage of catheter through urethra into the bladder)
  • assess for allergies (including latex, shellfish)
  • for women- dorsal recumbent position (supine w/ knees flexed- hips externally rotated). if pt can’t do this, assume a side-lying sims position w/ upper leg flexed at hip. must take extra precaution to cover the rectal area w/ drape to reduce chances of cross contamination
  • males-assist to supine position w/ thighs slight abducted (or Flowler’s position)
  • provide perineal care
  • ensure to lubricate 2.5-5cm of catheter for women and 12.5-17.7 for men
  • if the labia closes during cleaning then the produce must be repeated b/c now the area is contaminated
  • ask pt to bear down during insertion
  • advance catheter 5-7cm in adult female or until urine flows out of the catheter
  • advance catheter 17 to 22.5 cm in adult male or until urine comes out (then advance another 2.5-5cm)
72
Q

how long after should a pt void after removal of urinary indwelling catheter?

A

6-8 hrs, if they don’t notice prescriber

73
Q

management of catheter care

A
  • perform perineal hygiene at least twice (2-3x) daily, after a BM or as prn
  • ensure during perineal care not to advance the catheter upward into the bladder during cleaning as this action risks introducing bacteria into the bladder
  • encourage fluid intake at least 2000-2500 mL -flushes urine and keeps the catheter tubing free of sediment
  • observe pt for UTI symptoms
74
Q

catheter irrigations and installations

A

-irrigating the in-dwelling catheter using a triple-lumen catheter and sterile solution to maintain patency after urogenital surgery or to prevent blood clots from occulting the catheter
-called CBI
-occasionally the intermittent closed irrigation may be ordered if the catheter is occluded and it is deemed harmful to remove the catheter after a urological surgery
-if a catheter becomes occluded by sediment and encrustation, should be changed to avoid flushing debris containing bacteria into the bladder
-bladder irrigations or washouts to “unblock” such catheters that break the closed urinary drainage system risk of UTI
Maintenance of a closed system is essential during continuous or intermittent irrigations and instillations.

74
Q

catheter irrigations and installations

A

-irrigating the in-dwelling catheter using a triple-lumen catheter and sterile solution to maintain latency after urogenital surgery or to prevent blood clots from occulting the catheter
-called CBI
-occasionally the intermittent closed irrigation may be ordered if the catheter is occluded and it is deemed harmful to remove the catheter after a urological surgery
-if a catheter becomes occluded by sediment and encrustation, should be changed to avoid flushing debris containing bacteria into the bladder
-bladder irrigations or washouts to “unblock” such catheters that break the closed urinary drainage system risk of UTI
Maintenance of a closed system is essential during continuous or intermittent irrigations and instillations.

75
Q

removal of in-dwelling catheter

A
  • The patient may experience some discomfort when voiding after initial removal of the catheter. Until the bladder regains full tone, the patient may experience urinary frequency or retention. Ongoing com- plaints of dysuria and frequency may indicate an infection
  • The patient’s urinary function is assessed by noting the first voiding after catheter removal and by documenting the time and amount of voiding during the next 24 to 48 hours.
  • The nurse should record the time and amount of voids, including incontinence, on a bladder record. An ultrasound bladder scanner can assist with monitoring PVR urine. If amounts are small, frequent assessment for bladder distension, abdom- inal pain, dribbling, incontinence, and any sensation of incomplete empting is necessary. If 8 hours elapse without voiding or if the patient experiences discomfort, it may become necessary to reinsert the cath- eter
76
Q

interventions for CBI

A
  • examine tubing for kinks, clots, or urine sediment
  • evaluate bladder distention
  • Notify prescriber if irrigant is retained, if patient complains of pain, or if bladder is distended.
  • Assess for shock (check vital signs, skin colour, and moisture). • -Closed intermittent—stop irrigation
  • Closed continuous—leave flowing
  • Monitor fever
  • obtain sterile urine specimen if ordered
77
Q

unexpected outcomes for CBI

A
  • bright red bleeding w/ irrigation
  • increased cloudiness of urine, fever
  • increased pain
  • irrigating solutions doe not return or not flowing as prescribed rate, possible occlusion of catheter
  • if the urine is bright red/blood clots, increase irrigation rate until the drainage turns pink
78
Q

closed catheter irrigation considerations

A
  • irrigating fluid must remain sterile
  • draw sterile solution into syringe using aseptic technique
  • avoid cold solutions =can cause discomfort and bladder spasms
  • clamp the in-dwelling catheter just distal to the injection (specimen) port
  • clear port w/ antiseptic swab
  • slowly inject the fluid into catheter and bladder (slow, continuous pressure reduces trauma to the bladder wall)
  • w/draw syringe, remove clamp, and allow solution to drain into drainage bag
79
Q

closed continuous irrigation (w/ triple lumen catheter)

A
  • aseptique technique
  • insert top of sterile irrigation tubing into bag of sterile irrigating solution
  • close clamp on tubing and hang bag of solution on IV pole
  • open clamp and allow solution to flow through (prime) tubing, keeping the end of the tube sterile (remove air from tubing)
  • close clamp
  • wipe off irrigation port of triple-lumen catheter w/ antiseptic swab, and then attach to irrigating tubing
  • For intermittent flow, clamp tubing on drainage system, open clamp on irrigation tubing, and allow prescribed amount of fluid to enter bladder (100 mL is normal for adults). Close irrigation clamp and then open drainage tubing clamp
  • For continuous drainage, calculate drip rate and adjust clamp on irriga- tion tubing accordingly. Be sure that clamp on drainage tubing is open and check volume of drainage in drainage bag. Ensure that drainage tubing is patent, and avoid kinks
  • Calculate fluid used to irrigate bladder and catheter and subtract from total output
80
Q

suprapubic catheterization

A

involves surgical placement of a catheter through the abdominal wall above the symphysis pubis and into the urinary bladder

  • better option for comfort, but CAUTI can still occur
  • catheter is anchored in place w/ sutures
  • long-term suprapiubic catheter users may have a Foley catheter, once the rack is healed, nurses can change this device
  • urine drains into a urinary drainage bag
  • relatively painless and reduce the incidence of infection commonly seen w/ indwelling catheters
  • Sediment, clots, encrustations, or the abdominal wall itself can block the suprapubic catheter. Adequate fluid intake will help minimize the risk of blockage by sediment or infection due to stagnation
  • nurses should also administer skin care around the insertion site
81
Q

condom catheters

A
  • suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying. The condom is a soft, pliable sheath that slips over the penis. It may be worn at night only or continuously, depending on the patient’s needs
  • Care must be taken to ensure that whatever type or size of condom is used, blood supply to the penis is not impaired. Standard adhesive tape should never be used to secure a condom catheter because this tape does not expand with changes in penis size and is painful to remove
  • Condom catheters are associated with less risk of UTI, but infec- tions may result from buildup of secretions around the urethra, trauma to the urethral meatus, or buildup of pressure in the outflow tubing. Condom catheters must be applied and changed according to the manufacturers’ directions to prevent abrasion, dermatitis, ischemia, necrosis, edema, and maceration of the penis
82
Q

incontience-associated dermatitis (IAD)

A
  • prolonged exposure of skin to urine and stool can lead to inflammation and maceration resulting in IAD
  • Continuous exposure of the perineal area or skin around an ostomy can also lead to gradual maceration and excoriation
  • Washing with pH-balanced soap and warm water or no rinse cleanser is the best way to remove urine. Body lotion keeps skin moisturized and barrier cream products help protect the skin
83
Q

management to promote continence

A

-lifestyle changes, pelvic floor muscle exercises, bladder retraining, and toileting schedules for management of urgency’s stress, and mixed urinary incontience

84
Q

kegel exercises

A

improve the strength of pelvic floor muscles through hypertrophy and recruitment of additional muscle fibres associated w/ receptive contractions

  • These exercises are an evidence-informed treatment for stress incontinence, overactive bladders, and mixed causes of urinary incontinence
  • Patients begin these exercises by trying to suppress passing flatus rectally to teach them the correct muscles to contract.
  • hey also should be aware that it may take 12 to 16 weeks to notice appre- ciable change, but that maintaining the exercises is important in order to obtain a positive outcome.
85
Q

bladder training

A
  • goal is to increase gradually the interval between voids and to decease voiding frequency
  • The first step in bladder training is establishing a baseline. The patient or caregiver completes a urinary diary to assess maximum voiding interval
  • Urge suppression techniques, such as counting backward from 100 when the urge to void is felt and per- forming pelvic floor muscle contractions, are helpful

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