Week 4: Skin Integrity, Wounds, Urinary Elimination Flashcards
Types of Drains (5)
Gauze, Penrose, Chest tube, Hemovac, Jackson-Pratt, T-tube
Effects of Aging on the Bladder (4)
↓ Bladder elasticity, ↓ sensation to void, ↑ Nocturia, ↑ Urinary retention
Diseases Affecting Urinary Function (7)
Congenital abnormalities, kidney disease, UTI, urinary calculi, diabetes, hypertension, gout
Types of Urinary Incontinence (7)
Transient, Mixed, Overflow, Functional, Reflex, Total, Stress
Types of Catheters (4)
Intermittent, Indwelling (foley), Suprapubic, Condom Catheter
Reasons for Catheterization (4)
Urinary retention, sterile specimen collection, pre/post-op emptying, monitoring critically ill patients
Urinary Elimination Diagnostic Tests (5)
KUB X-ray, IVP, ultrasound, cystoscopy, CT scan
5 major bony prominences
- Back of head
- Shoulders
- Elbows
- Buttocks
- Heels
3 ways to promote perfusion
Leg exercises, sequential compression device (SCDs), TED stockings
Braden Scale: 6 aspects of assessment
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
Braden Scale: Scoring
Reverse scoring on a 1-4 scale, except friction and shear is a 1-3 score
The lower the score the higher the risk
Pressure ulcers: Stage I
Non-blanchable erythema; skin is intact
Pressure ulcers: Stage II
Partial thickness loss involving both epidermis and dermis
Pressure ulcers: Stage III
Full thickness loss; subcutaneous tissue/fat is visible
Pressure ulcers: Stage IV
Full thickness loss; bone and muscle is visible
Pressure ulcers: Unstageable
Eschar involved, unstageable until eschar is removed
Risks for pressure injuries (8)
- Age-related
- Chronic illness-e.g., end-stage renal disease, diabetes, anemia, atherosclerosis
- Use of steroids
- Immobility
- Bedridden
- Malnutrition
- Moisture & Incontinence
- Altered LOC
Micturition volume: Urge to void
150-250 mL
Micturition volume: Stretch reflex
350-400 mL
Micturition volume: Loss of control
700 mL
Effects of medications on urine production and
elimination: Diuretics
Prevent reabsorption of water and certain electrolytes in tubules
Inc. urine output
Effects of medications on urine production and
elimination: Cholinergic medications
Stimulate contraction of detrusor muscle
Inc. urine elimination
Effects of medications on urine production and
elimination: Analgesics and tranquilizers
Suppress CNS, diminishing effectiveness of neural reflex
Dec. urine elimination
Medications affecting color of urine: Anticoagulants
Red urine
