Week 2 Flashcards
Urinary elimination assessment
General appearance
Urine
Abdomen
Lab results
Use of elimination devices
General - urinary assessment
Dietary habits
Age
Body position
Edema
Water intake
Activity level
History of UTI etc
Medications
Urine assessment
Colour
Transparency
Odour
Volume
Specific gravity
pH
Urine colours and what they mean
None - altered kidney function
Yellow-orange - liver/GB dysfunction
Red brown - trauma/bleed
Brown black - excretion of melanin
Whitish - bacteria present
Cloudy urine
Presence of cells, bacteria
Urine odour
Strong - vitamins
Ammonia - infection
Fecal - fistula
Volumes of urine
Infant - 500-600ml
Tots - 500-800ml
Child 600-1200
Oliguria - less than 500/d
Polyuria - more than 2500/d
Bladder can store 3-600ml
Specific gravity
Measures urine concentration
1.003-1.030
Elderly 1.016-1.022
PH of urine
5-7
Increased alkalinity is noted with bacterial infection
Lab test assess for
Electrolytes
Cells
(Epithelial = necrosis)
Urine habits
Voiding patterns
- frequency
- olig/polyuria
- nocturia
- dribbling
Continence
Assistive devices
Abdomen assessment - urinary
Bladder palpation/auscultation
Scars from any past surgery
Assess for pain
Assess genitourinary structures
- redness, thinning, odour, discharge
Urinalysis
Clean area before collection
Morning preferred
Midstream
Promoting urinary elimination
Be aware of personal habits (time etc)
Establish privacy
Establish routine
Promote fluid intake
Monitor output
Assess skin for any breakdown
Teach pericare if possible
General assess ment of bowel elimination
Dietary habits
Patterns
Activity
History
Medication
Bowel elimination - abdomen
Abdomen
- flat, soft, hollow
- assess growth
- bowel sounds
- 5-15s between
Bowel elimination - anus
Skin intact
Tightly closed
Free of lesions and secretions
Assess for external hemorrhoids
Assess muscle tone and tenderness
Bowel elimination - rectum
Assess for prolapse
Assess stool accumulation
Palpate prostate, cervix/uterus, masses
Gluteal folds
- pink, intact
Bowel elimination - colours and what they mean
Dark brown to black - iron
Black - old blood
Green - spinach, laxatives (age dependent)
White/grey - indigestion of barium, poor bilirubin pigment absorption
Red - beets/bleeding
Yellow - excess fat
Bowel elimination - stool consistancy and shape, volume
Soft and tubular
Vol
- 100-200g/d
Stool characteristics
Odour
- varies by diet
- decay - cancer
Composition
- 75% water
- food residue, intestinal fluid, pigments, epithelial cells,
Bowel lab tests
Stool for occult blood
Abdominal X-ray
- determine extent/distribution of feces
Promoting bowel function
Assess number of BM
Patterns
Use of laxes prn
Diet, use fibre
Assess distension in abdomen
Encourage a balanced diet
Assese activity level
Provide skin care, document status
Stoma assessment
PWR
Pink warm raised (should be flush with skin)
Appliance parts
Phalange - holds pouch to stoma
Pouch - hold contents
Occult blood stool specimen collection
Stool only - no contamination
2 samples per, from different sides of stick/sample
Air dry 1 day
Add solutions, wait 60s
