Week Eight Flashcards
1
Q
Anuria
A
lack of urine output
3
Q
Diuresis or polyuria
A
Abnormally large amounts of urine
4
Q
Oliguria
A
Scant amount of urine, <30 mL / hour
5
Q
Hematuria
A
blood in the urine
6
Q
Distention
A
overfilling of the bladder resulting in muscle stretching. verified by physical assessment of the bladder
7
Q
Percussion
A
body surface is lightly struck to assess sounds or vibrations
8
Q
Palpation
A
assessment of body areas using sense of touch
9
Q
Retention
A
Accumulation of urine in the bladder with associated inability to empty
10
Q
Retention with overflow
A
dribbling incontinence or urinary frequency with a full bladder, inability to respond adequately to urge to void
11
Q
Bladder Scan
A
Bladder is assessed using ultrasound to determine retention or residual urine. non-invasive, portable, easy/painless
12
Q
Catheterization for Residual Urine
A
Measures the amount of urine left in the bladder after the patient voids. Patient voids then is catheterized. Normal “Residual” = No urine to a few mL
13
Q
Normal “Residual =
A
No urine to a few mL
14
Q
Cystitis
A
inflammation of the urinary bladder and ureters
15
Q
Functions of Urinary System
A
Assist in maintaining fluid/electrolyte balance and remove waste products
16
Q
Characteristics of the Urinary System
A
Closed or Sterile System
17
Q
Anatomy of Urinary System
A
Kidneys, Ureters, Bladder, Urethra
18
Q
Kidneys Function
A
Filter fluid, electrolytes, waste products
19
Q
Ureters Function
A
Passageway for urine from kidneys to bladder
20
Q
Bladder Function
A
Reservoir or collecting chamber for urine, muscle which can distend or stretch
21
Q
Bladder Capacity
A
300-600 mL urine
22
Q
Urethra Function
A
Passageway for urine out of the body through the urinary meatus
23
Q
Process of Micturition
A
Urine collects in the bladder –> Pressure stimulates stretch receptors in bladder (250-450mL) –> impulse transmitted to voiding reflex center in the sacral area –> Internal sphincter relaxes and stimulates urge to void….If the time and place is appropriate, the relaxation of the internal sphincter = voiding/micturition. If the time and place is not appropriate the voiding reflex subsides until the bladder becomes more filled and the internal sphincter will again relax
24
Q
Micturition
A
the process of urinating
25
Q
Infants Urinary
A
Immature kidneys, small bladder, liquid diet
26
Times per day infants void
Up to 20X per day
27
Preschoolers Urinary
Cognitive ability to respond to urge to void, potty training
28
School Age
Kidneys double in size between 5-10 years, larger bladder
29
Times per day school age children void
6-8X/day
30
Elderly Urinary
Urinary muscles lose elasticity and sensation, chemical response to fluid/electrolyte imbalance less effective, cognitive impairment, impaired mobility
31
Factors that affect the volume of urine and the voiding process
Muscle Tone
40
Muscle Tone
Poor muscle tone = inadequate bladder control
41
Medication
volume of urine, muscle tone of bladder, various effects
42
Interruption of Flow
Hypertrophy of the prostate, renal calculi
43
Renal Calculi
Kidney stone
44
Diseases that effect kidney function
diabetes, hypertension
45
Surgical Procedures
cystoscopy
46
Normal Color of Urine
Straw or amber colored
47
Normal Odor of Urine
Faint aromatic
48
Turbidity
clarity
49
Turbidity of Normal Urine
clear
50
Amount Normal Urine
1,500 mL - 2,500 mL/ 24 hours
51
Composition of Normal Urine
94% water, 4% solutes (Na+, Cl-, urea, ammonia, creatinine)
52
Acetone (Ketone bodies)
End product of breakdown of fatty tissues
53
Acetone Normal
0
54
Albumin/Protein
Should remain in the blood vessels during filtration through the kidneys
55
Albumin/Protein Normal
0
56
Red Blood Cells Normal
0 but normal during menstation
57
Glucose Normal
0
58
Glucose
should remain in blood vessels during filtration through the kidneys
59
White Blood Cells
only present with infection or inflammation
60
White Blood Cells Normal
0-5
61
Casts
Compressed protein/cells/debris formed in the kidney tubules
62
Casts Normal
0
63
Specific Gravity
concentration of solutes in urine
64
Specific Gravity Normal
1.010 - 1.025
65
pH
concentration of hydrogen ions in the urine
66
Alkaline Urine
common with urinary infection
67
Acidic urine
common with diseases of metabolism
68
pH Normal
4.5-8
69
Dysuria
painful urination
70
Urgency
sudden need to void regardless of amount of urine in the bladder
71
Frequency
voiding more often
72
Nocturia
frequency at night not r/t increased fluid intake > or equal to 2X/night
73
Enuresis
repeated involuntary urination in children beyond the age when voluntary bladder control is normal acquired
74
Incontinence
Inability of the external sphincter muscles to control the flow of urine from the bladder
75
What information should be collected during a nursing history when assessing the client's ability to meet the need for urinary elimination?
changes from normal patterns, dysuria, urgency, frequency, nocturia, enuresis, incontinence, urinary output, diuresis, oliguria, anuria, hematuria, distention, retention, retention c overflow
76
Urethral Orifice for Females
Between the clitoris and vagina
77
Urethral Orifice for Males
Tip of penis
78
Assess urethral orifice for
swelling, inflammation, discharge, discomfort
79
Functional Urinary Incontinence
The inability of a usually continent person to reach toilet in time to avoid unintentional loss of urine
80
Functional Urinary incontinence r/t
cognitive disorders, neuromuscular limitations, impairing mobility, environmental barrier to toileting
81
Total Urinary Incontinence
continuous urine output with no identifiable voiding reflex
82
Total Urinary Incontinence r/t
neurogenic disorder
83
Urinary Retention
Incomplete emptying of the bladder r/t bladder outlet obstruction, prostate cancer, constipation, benign prostatic hypertrophy
84
Defining characteristics functional urinary incontinence
immobility, fecal impaction, constipation, decreased awareness/confusion, UTI, vaginal infection, medication, depression, lack of privacy, impaired communication, inconvenient facilities, past medical history of UTI, surgery/trauma, STD's, multiple vaginal births, change in urinary habits, amount, urine characteristics
85
Defining characteristics of urinary retention
residual urine greater than 150-250mL, urgency, freq, nocturia, overflow
86
Nursing interventions for altered urinary elimination
treat underlying cause if possible, frequent toileting, use tact and understanding, encourage verbalization of feelings, encourage privacy, assist with perineal/genital care, environmental alterations, bladder training to decrease urgency and frequency, habit training via scheduled voiding, prompted voiding, pelvic muscle exercise, protective skin barrier creams, monitor skin q shift, incontinence briefs, absorbent pads or liners, external condom catheters, indwelling catheterization only if absolutely necessary
87
Outcome for altered urinary elimination
achieve bladder control, restore normal elimination pattern
88
Promotion of Normal Elimination
drink 8-10 oz glasses of water/day, avoid excessive sodium intake, respond to the urge to void ASAP, run water to stimulate micturition, apply gentle pressure on the bladder, notify provider of any abnormal subjective data
89
Prevention of urinary tract infections associated with catheters
insert catheters only for appropriate indications, leave catheters in place only as long as needed, ensure that only properly trained persons insert and maintain catheters, insert catheters using sterile technique, maintain a closed drainage system, maintain unobstructed urine flow, practice hand hygiene
90
prevention of cystitis
2,500 mL fluid/day, void when urge is felt, void before and after sex, proper perineal care, avoid bubble baths, harsh soaps and powder, avoid synthetic underwear, avoid tight fitting clothing that restricts urethra
91
Signs of UTI
frequency, urgency, dysuria
92
Main functions of large intestine
absorption of h20 and nutrients
97
Factors affecting bowel function
developmental stage, diet, fluid intake 2,000-2,000 mL a day, activity, psychological factors, defecation habits, medications, diagnostic procedures, anesthesia and surgery, pathologic conditions, pain
98
Newborn Bowel
immature intestine, water is not well absorbed, less bacterial flora, pass frequent, soft, liquid stools, meconium X 24 hours and transitional stools X 1 week, breast fed yellow mustard seed stools
99
Toddler Bowel
some control, toilet training begins when aware of discomfort of dirty diaper and recognition to defecate
100
School Age Bowel
May delay defecation because of an activity
101
Older Adults
Constipation is a problem, evaluate any complaint of constipation
102
Normal Stool Color
Brown-Yellow
103
Normal Stool Consistency
formed, soft, semi-solid, moist
104
Normal Stool Shape
cylindrical
105
Constipated Stool Color
dark
106
Constipated Stool Consistency
small, dry, hard
107
Constipated Stool Shape
pellet
108
Constipated Stool Amount/freq
fewer than 3 times a week in small amounts
109
Diarrhea Color
variable
110
Diarrhea Consistency
liquid
111
Diarrhea Shape
unformed
112
Diarrhea freq
increased
113
Nursing History Assessment Bowel
defecation pattern, characteristics of stool, fecal elimination problem identification, factors influencing elimination
114
How much fiber per day?
20-35grams
115
Nursing measures that promote normal/regular defecation
privacy, timing, nutrition, fluids, exercise, positioning
116
Causes of Constipation
insufficient fiber intake, insuff fluid intake, insuff activity, immobility, irregular defecating habits, change in daily routine, lack of privacy, chronic laxative/enema use, irritable bowel syndrome, pelvic floor dysfunction or muscle damage, poor motility or slow transit, neurological conditions, emotional disturbance, habitual denial of the urge to defecate
117
Causes of Fecal Impaction
Prolonged retention and accumulation of fecal matter caused by poor defecation habits, history of constipation, and certain medications like barium
118
Causes of Fecal Incontinence
Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter, caused by impaired functioning of the anal sphincter or its nerve supply, such as in neuromuscular disease, spinal cord trauma and tumors of the external anal sphincter, also seen in clients with advanced brain disease
119
Causes of Diarrhea
psychological stress, medications, allergies, food/fluid intolerances, diseases of the colon, clostridium difficile-associated disease and surgical operations
120
Causes of Flatulence
The presence of excessive gas in the intestines causing stretching and inflation of the intestines. May be caused by certain foods, abdominal surgery, narcotics, action of bacteria on the chyme in the large intestine, swallowed air or gas that diffuses between the bloodstream and the intestine
121
Definition of perceived constipation
Expectations of a daily bowel movement that results in overuse of laxatives, enemas, or suppositories; expectation of passage of stool at same time every day
122
Bowel Training Programs
Based on factors within the client's control with goal to establish normal defecation. Clients need to understand and agree with the program's philosophy. Participation in the program is voluntary.
123
Common Bowel Medications
Ioperamide, Bisacodyl, Docusate, Psyllium hydrophilic mucilloid, Magnesium hydroxide
124
Loperadmide (Imodium)
antidiarrheal agent
125
Bisacodyl (Dulcolax)
stimulant laxative
126
Docusate Sodium (Colace)
stool softener
127
Psyllium hydrophilic mucilloid (metamucil)
bulk laxative
128
Magnesium Hydroxide (Milk of Magnesia)
saline cathartic, antacid
129
Bowel Sounds
The normal sounds associated with movement of the intestinal contents through the alimentary tract. Auscultate the abdomen for this because it may provide valuable diagnostic information. Absent or diminished sounds may indicate paralytic ileus or peritonitis. High-pitched tinkling sounds are associated with intestinal obstruction.
130
Cathartic
purgative; medicine that causes the bowels to empty; ADJ.
131
Defecation
the elimination of fecal waste through the anus
132
Diarrhea
frequent discharge of liquid stool
133
Enema
injection of a liquid through the anus to stimulate evacuation
134
Feces
solid excretory product evacuated from the bowels
135
Flatus
gas expelled through the anus
136
Hemorrhoids
swollen, twisted, varicose veins in the rectal region
137
Impaction
a disorder in which feces are impacted in the lower colon
138
Peristalsis
the process of wave-like muscle contractions of the alimentary tract that moves food along
139
Rectal Tube
A plastic or rubber tube designed for insertion into the rectum; when written as a doctor's order, rectal tube means the insertion of a rectal tube into the rectum to remove gas and relieve distention.
140
Stool
excreted feces
141
Suppository
medicated substance mixed in a solid base that melts when placed in a body opening; suppositories are commonly used in the rectum, vagina, or urethra
142
Planning
The deliberate, systematic third phase of the nursing process that involves decision making and problem solving. Uses assessment data and problem solving for direction in formulating client goals and therapeutic nursing interventions
143
When does planning happen?
Begins with the first contact and continues until the nurse-client relationship ends
144
Client Goal
Broad statement about an observable client condition achieved by implementing nursing interventions.
145
Outcome Criteria
Specific criteria that focus on observable/measurable results of health care team activities. Stepping stones to reaching the outcome.
146
Step: Prioritize problems/diagnoses
Choose nursing diagnoses using maslow's and sort them by high, intermediate, low priority
147
Step: Formulate Desired Outcomes
identify desirable human responses, evaluate a client's progress (resolved, prevented, reduced), provide direction for planning TNI's, motivate client and nurse sense of achievement, client centered, observable (SMART)
148
SMART
specific, measurable, appropriate, realistic, timely
149
TEA
Time frame, expected behavior, action verb
150
Foley Catheter
Indwelling catheter inserted through the urethra into the bladder; includes a collection system that allows urine to be drained into a bag--can remain in place for an extended time
151
Straight Catheter
a catheter that drains the bladder and then is removed
152
Lithotomy position
a position lying on your back with knees bent and thighs apart
153
Clean Catch Urine
Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI
154
Midstream urine
Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI
155
Urinalysis
To determine urine composition and possible abnormal components or infection
156
Urine for culture and sensitivity
Determine the presence of microorganisms, the type of organisms, and the antibiotics to which the organisms are sensitive
