Set 10 Flashcards
How many mL of urinary output per day is considered normal?
1500 mL (1.5 L)
Alert the provider if urine is less than ___ mL/hr
30
Concentration of urine
Urine specific gravity
Normal range for urine specific gravity
1.005-1.030
Low specific gravity = __________ urine
Dilute
High specific gravity = _________ urine
Concentrated
Patient education for 24 hour urine collection
Discard the first void of the day; keep container refrigerated
Leakage of urine as a result of intra-abdominal pressure (coughing, sneezing, jumping, laughing)
Stress incontinence
Who is most at risk for stress incontinence?
Patients who have multiple pelvic surgeries or pregnancies/deliveries due to weakened pelvic floor
Type of incontinence characterized by inability to make it to the bathroom when there is an urge to urinate
Urge incontinence
Who is most at risk for urinary tract infections?
Females due to shorter urethra
S/S of UTI
Abdominal pain, dysuria (painful urination), frequency, urgency burning, malodorous urine
Key signs of UTI in older adults
Confusion and abdominal pain (may not present with classical symptoms)
Patient education for prevention of UTI
- wipe front to back
- wear cotton underwear
- avoid bubble baths
- empty bladder regularly
- urinate after penetrative vaginal intercourse
- increase fluid intake; cranberry juice
Placement of bladder scanner transducer
Approximately 1 in above the pubic symphysis pointed down towards bladder
Biggest concern for patients with indwelling (foley) catheter
Risk for catheter-associated UTI (CAUTI)
Biggest risk associated with external catheters
Skin breakdown
Indwelling catheter care
- use STERILE technique during insertion
- keep bag below bladder
- assess for kinks/loops
- remove as soon as appropriate
The nurse should educate constipated patients to increase
Fluids, dietary fiber, activity
BRAT diet for diarrhea
Bananas, rices, applesauce, toast
Patients with diarrhea are at risk for
Fluid volume deficit (increase fluid intake), impaired skin integrity
Surgical openings that divert the normal passage of the bowel
Ostomies
Surgical opening created in the ileum of the small intestine
Ileostomy
Describe output from an ileostomy
Frequent, liquidy stools
Surgical opening created in the colon/large intestine
Colostomy
Describe the output of colostomies depending on location
Output is going to be more formed the closer it is to the rectum:
- ascending colon — watery
- transverse colon — semisolid, pudding-like consistency
- sigmoid colon — formed stool
When should ostomy bags be changed?
When it is 1/3 full or immediately if it is leaking
Characteristics of a normal, healthy stomach
Red/pink in color, moist (indicates good blood supply)
Stoma findings that should be reported to the provider
Pale, cool, dusky, blue (indicative of ischemia)
Part of ostomy device that sticks to the patient’s skin
Wafer
Patient education for cutting/fitting of ostomy wafer
- measure stoma
- cut opening less than or equal to 1/8 inch wider in diameter
Insertion of rectal suppository
- patient in sims position
- insert suppository about 1 inch into rectum (past the internal sphincter)
Enema solution should be less than or equal to ___ inches above the patient
18
What should the nurse do if patient complains of cramping during instillation of enema?
Lower the bag (slows rate of delivery)
The nurse should instruct the patient receiving an enema to resist the urge to toilet for approximately ___ minutes or as prescribed per order
10
Testing for the presence of blood in the feces that is not seen
Fecal occult blood test
For fecal occult blood testing, blood is present if the card turns __________ after developer is added
Blue (NOTE: no color change in the absence of blood)
