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Semester One - Nursing 111 > Week Eight > Flashcards

Week Eight Flashcards

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1
Q

Anuria

A

lack of urine output

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3
Q

Diuresis or polyuria

A

Abnormally large amounts of urine

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4
Q

Oliguria

A

Scant amount of urine, <30 mL / hour

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5
Q

Hematuria

A

blood in the urine

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6
Q

Distention

A

overfilling of the bladder resulting in muscle stretching. verified by physical assessment of the bladder

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7
Q

Percussion

A

body surface is lightly struck to assess sounds or vibrations

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8
Q

Palpation

A

assessment of body areas using sense of touch

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9
Q

Retention

A

Accumulation of urine in the bladder with associated inability to empty

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10
Q

Retention with overflow

A

dribbling incontinence or urinary frequency with a full bladder, inability to respond adequately to urge to void

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11
Q

Bladder Scan

A

Bladder is assessed using ultrasound to determine retention or residual urine. non-invasive, portable, easy/painless

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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

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13
Q

Normal “Residual =

A

No urine to a few mL

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14
Q

Cystitis

A

inflammation of the urinary bladder and ureters

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15
Q

Functions of Urinary System

A

Assist in maintaining fluid/electrolyte balance and remove waste products

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16
Q

Characteristics of the Urinary System

A

Closed or Sterile System

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17
Q

Anatomy of Urinary System

A

Kidneys, Ureters, Bladder, Urethra

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18
Q

Kidneys Function

A

Filter fluid, electrolytes, waste products

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19
Q

Ureters Function

A

Passageway for urine from kidneys to bladder

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20
Q

Bladder Function

A

Reservoir or collecting chamber for urine, muscle which can distend or stretch

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21
Q

Bladder Capacity

A

300-600 mL urine

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22
Q

Urethra Function

A

Passageway for urine out of the body through the urinary meatus

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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

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24
Q

Micturition

A

the process of urinating

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25
Q

Infants Urinary

A

Immature kidneys, small bladder, liquid diet

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26
Q

Times per day infants void

A

Up to 20X per day

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27
Q

Preschoolers Urinary

A

Cognitive ability to respond to urge to void, potty training

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28
Q

School Age

A

Kidneys double in size between 5-10 years, larger bladder

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29
Q

Times per day school age children void

A

6-8X/day

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30
Q

Elderly Urinary

A

Urinary muscles lose elasticity and sensation, chemical response to fluid/electrolyte imbalance less effective, cognitive impairment, impaired mobility

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31
Q

Factors that affect the volume of urine and the voiding process

A

Muscle Tone

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40
Q

Muscle Tone

A

Poor muscle tone = inadequate bladder control

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41
Q

Medication

A

volume of urine, muscle tone of bladder, various effects

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42
Q

Interruption of Flow

A

Hypertrophy of the prostate, renal calculi

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43
Q

Renal Calculi

A

Kidney stone

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44
Q

Diseases that effect kidney function

A

diabetes, hypertension

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45
Q

Surgical Procedures

A

cystoscopy

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46
Q

Normal Color of Urine

A

Straw or amber colored

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47
Q

Normal Odor of Urine

A

Faint aromatic

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48
Q

Turbidity

A

clarity

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49
Q

Turbidity of Normal Urine

A

clear

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50
Q

Amount Normal Urine

A

1,500 mL - 2,500 mL/ 24 hours

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51
Q

Composition of Normal Urine

A

94% water, 4% solutes (Na+, Cl-, urea, ammonia, creatinine)

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52
Q

Acetone (Ketone bodies)

A

End product of breakdown of fatty tissues

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53
Q

Acetone Normal

A

0

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54
Q

Albumin/Protein

A

Should remain in the blood vessels during filtration through the kidneys

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55
Q

Albumin/Protein Normal

A

0

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56
Q

Red Blood Cells Normal

A

0 but normal during menstation

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57
Q

Glucose Normal

A

0

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58
Q

Glucose

A

should remain in blood vessels during filtration through the kidneys

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59
Q

White Blood Cells

A

only present with infection or inflammation

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60
Q

White Blood Cells Normal

A

0-5

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61
Q

Casts

A

Compressed protein/cells/debris formed in the kidney tubules

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62
Q

Casts Normal

A

0

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63
Q

Specific Gravity

A

concentration of solutes in urine

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64
Q

Specific Gravity Normal

A

1.010 - 1.025

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65
Q

pH

A

concentration of hydrogen ions in the urine

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66
Q

Alkaline Urine

A

common with urinary infection

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67
Q

Acidic urine

A

common with diseases of metabolism

68
Q

pH Normal

A

4.5-8

69
Q

Dysuria

A

painful urination

70
Q

Urgency

A

sudden need to void regardless of amount of urine in the bladder

71
Q

Frequency

A

voiding more often

72
Q

Nocturia

A

frequency at night not r/t increased fluid intake > or equal to 2X/night

73
Q

Enuresis

A

repeated involuntary urination in children beyond the age when voluntary bladder control is normal acquired

74
Q

Incontinence

A

Inability of the external sphincter muscles to control the flow of urine from the bladder

75
Q

What information should be collected during a nursing history when assessing the client’s ability to meet the need for urinary elimination?

A

changes from normal patterns, dysuria, urgency, frequency, nocturia, enuresis, incontinence, urinary output, diuresis, oliguria, anuria, hematuria, distention, retention, retention c overflow

76
Q

Urethral Orifice for Females

A

Between the clitoris and vagina

77
Q

Urethral Orifice for Males

A

Tip of penis

78
Q

Assess urethral orifice for

A

swelling, inflammation, discharge, discomfort

79
Q

Functional Urinary Incontinence

A

The inability of a usually continent person to reach toilet in time to avoid unintentional loss of urine

80
Q

Functional Urinary incontinence r/t

A

cognitive disorders, neuromuscular limitations, impairing mobility, environmental barrier to toileting

81
Q

Total Urinary Incontinence

A

continuous urine output with no identifiable voiding reflex

82
Q

Total Urinary Incontinence r/t

A

neurogenic disorder

83
Q

Urinary Retention

A

Incomplete emptying of the bladder r/t bladder outlet obstruction, prostate cancer, constipation, benign prostatic hypertrophy

84
Q

Defining characteristics functional urinary incontinence

A

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
Q

Defining characteristics of urinary retention

A

residual urine greater than 150-250mL, urgency, freq, nocturia, overflow

86
Q

Nursing interventions for altered urinary elimination

A

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
Q

Outcome for altered urinary elimination

A

achieve bladder control, restore normal elimination pattern

88
Q

Promotion of Normal Elimination

A

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
Q

Prevention of urinary tract infections associated with catheters

A

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
Q

prevention of cystitis

A

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
Q

Signs of UTI

A

frequency, urgency, dysuria

92
Q

Main functions of large intestine

A

absorption of h20 and nutrients

97
Q

Factors affecting bowel function

A

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
Q

Newborn Bowel

A

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
Q

Toddler Bowel

A

some control, toilet training begins when aware of discomfort of dirty diaper and recognition to defecate

100
Q

School Age Bowel

A

May delay defecation because of an activity

101
Q

Older Adults

A

Constipation is a problem, evaluate any complaint of constipation

102
Q

Normal Stool Color

A

Brown-Yellow

103
Q

Normal Stool Consistency

A

formed, soft, semi-solid, moist

104
Q

Normal Stool Shape

A

cylindrical

105
Q

Constipated Stool Color

A

dark

106
Q

Constipated Stool Consistency

A

small, dry, hard

107
Q

Constipated Stool Shape

A

pellet

108
Q

Constipated Stool Amount/freq

A

fewer than 3 times a week in small amounts

109
Q

Diarrhea Color

A

variable

110
Q

Diarrhea Consistency

A

liquid

111
Q

Diarrhea Shape

A

unformed

112
Q

Diarrhea freq

A

increased

113
Q

Nursing History Assessment Bowel

A

defecation pattern, characteristics of stool, fecal elimination problem identification, factors influencing elimination

114
Q

How much fiber per day?

A

20-35grams

115
Q

Nursing measures that promote normal/regular defecation

A

privacy, timing, nutrition, fluids, exercise, positioning

116
Q

Causes of Constipation

A

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
Q

Causes of Fecal Impaction

A

Prolonged retention and accumulation of fecal matter caused by poor defecation habits, history of constipation, and certain medications like barium

118
Q

Causes of Fecal Incontinence

A

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
Q

Causes of Diarrhea

A

psychological stress, medications, allergies, food/fluid intolerances, diseases of the colon, clostridium difficile-associated disease and surgical operations

120
Q

Causes of Flatulence

A

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
Q

Definition of perceived constipation

A

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
Q

Bowel Training Programs

A

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
Q

Common Bowel Medications

A

Ioperamide, Bisacodyl, Docusate, Psyllium hydrophilic mucilloid, Magnesium hydroxide

124
Q

Loperadmide (Imodium)

A

antidiarrheal agent

125
Q

Bisacodyl (Dulcolax)

A

stimulant laxative

126
Q

Docusate Sodium (Colace)

A

stool softener

127
Q

Psyllium hydrophilic mucilloid (metamucil)

A

bulk laxative

128
Q

Magnesium Hydroxide (Milk of Magnesia)

A

saline cathartic, antacid

129
Q

Bowel Sounds

A

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
Q

Cathartic

A

purgative; medicine that causes the bowels to empty; ADJ.

131
Q

Defecation

A

the elimination of fecal waste through the anus

132
Q

Diarrhea

A

frequent discharge of liquid stool

133
Q

Enema

A

injection of a liquid through the anus to stimulate evacuation

134
Q

Feces

A

solid excretory product evacuated from the bowels

135
Q

Flatus

A

gas expelled through the anus

136
Q

Hemorrhoids

A

swollen, twisted, varicose veins in the rectal region

137
Q

Impaction

A

a disorder in which feces are impacted in the lower colon

138
Q

Peristalsis

A

the process of wave-like muscle contractions of the alimentary tract that moves food along

139
Q

Rectal Tube

A

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
Q

Stool

A

excreted feces

141
Q

Suppository

A

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
Q

Planning

A

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
Q

When does planning happen?

A

Begins with the first contact and continues until the nurse-client relationship ends

144
Q

Client Goal

A

Broad statement about an observable client condition achieved by implementing nursing interventions.

145
Q

Outcome Criteria

A

Specific criteria that focus on observable/measurable results of health care team activities. Stepping stones to reaching the outcome.

146
Q

Step: Prioritize problems/diagnoses

A

Choose nursing diagnoses using maslow’s and sort them by high, intermediate, low priority

147
Q

Step: Formulate Desired Outcomes

A

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
Q

SMART

A

specific, measurable, appropriate, realistic, timely

149
Q

TEA

A

Time frame, expected behavior, action verb

150
Q

Foley Catheter

A

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
Q

Straight Catheter

A

a catheter that drains the bladder and then is removed

152
Q

Lithotomy position

A

a position lying on your back with knees bent and thighs apart

153
Q

Clean Catch Urine

A

Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI

154
Q

Midstream urine

A

Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI

155
Q

Urinalysis

A

To determine urine composition and possible abnormal components or infection

156
Q

Urine for culture and sensitivity

A

Determine the presence of microorganisms, the type of organisms, and the antibiotics to which the organisms are sensitive

Semester One - Nursing 111 (15 decks)

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