Week Eight Flashcards
Anuria
lack of urine output
Diuresis or polyuria
Abnormally large amounts of urine
Oliguria
Scant amount of urine, <30 mL / hour
Hematuria
blood in the urine
Distention
overfilling of the bladder resulting in muscle stretching. verified by physical assessment of the bladder
Percussion
body surface is lightly struck to assess sounds or vibrations
Palpation
assessment of body areas using sense of touch
Retention
Accumulation of urine in the bladder with associated inability to empty
Retention with overflow
dribbling incontinence or urinary frequency with a full bladder, inability to respond adequately to urge to void
Bladder Scan
Bladder is assessed using ultrasound to determine retention or residual urine. non-invasive, portable, easy/painless
Catheterization for Residual Urine
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
Normal “Residual =
No urine to a few mL
Cystitis
inflammation of the urinary bladder and ureters
Functions of Urinary System
Assist in maintaining fluid/electrolyte balance and remove waste products
Characteristics of the Urinary System
Closed or Sterile System
Anatomy of Urinary System
Kidneys, Ureters, Bladder, Urethra
Kidneys Function
Filter fluid, electrolytes, waste products
Ureters Function
Passageway for urine from kidneys to bladder
Bladder Function
Reservoir or collecting chamber for urine, muscle which can distend or stretch
Bladder Capacity
300-600 mL urine
Urethra Function
Passageway for urine out of the body through the urinary meatus
Process of Micturition
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
Micturition
the process of urinating
Infants Urinary
Immature kidneys, small bladder, liquid diet
Times per day infants void
Up to 20X per day
Preschoolers Urinary
Cognitive ability to respond to urge to void, potty training
School Age
Kidneys double in size between 5-10 years, larger bladder
Times per day school age children void
6-8X/day
Elderly Urinary
Urinary muscles lose elasticity and sensation, chemical response to fluid/electrolyte imbalance less effective, cognitive impairment, impaired mobility
Factors that affect the volume of urine and the voiding process
Muscle Tone
Muscle Tone
Poor muscle tone = inadequate bladder control
Medication
volume of urine, muscle tone of bladder, various effects
Interruption of Flow
Hypertrophy of the prostate, renal calculi
Renal Calculi
Kidney stone
Diseases that effect kidney function
diabetes, hypertension
Surgical Procedures
cystoscopy
Normal Color of Urine
Straw or amber colored
Normal Odor of Urine
Faint aromatic
Turbidity
clarity
Turbidity of Normal Urine
clear
Amount Normal Urine
1,500 mL - 2,500 mL/ 24 hours
Composition of Normal Urine
94% water, 4% solutes (Na+, Cl-, urea, ammonia, creatinine)
Acetone (Ketone bodies)
End product of breakdown of fatty tissues
Acetone Normal
0
Albumin/Protein
Should remain in the blood vessels during filtration through the kidneys
Albumin/Protein Normal
0
Red Blood Cells Normal
0 but normal during menstation
Glucose Normal
0
Glucose
should remain in blood vessels during filtration through the kidneys
White Blood Cells
only present with infection or inflammation
White Blood Cells Normal
0-5
Casts
Compressed protein/cells/debris formed in the kidney tubules
Casts Normal
0
Specific Gravity
concentration of solutes in urine
Specific Gravity Normal
1.010 - 1.025
pH
concentration of hydrogen ions in the urine
Alkaline Urine
common with urinary infection
Acidic urine
common with diseases of metabolism
pH Normal
4.5-8
Dysuria
painful urination
Urgency
sudden need to void regardless of amount of urine in the bladder
Frequency
voiding more often
Nocturia
frequency at night not r/t increased fluid intake > or equal to 2X/night
Enuresis
repeated involuntary urination in children beyond the age when voluntary bladder control is normal acquired
Incontinence
Inability of the external sphincter muscles to control the flow of urine from the bladder
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
Urethral Orifice for Females
Between the clitoris and vagina
Urethral Orifice for Males
Tip of penis
Assess urethral orifice for
swelling, inflammation, discharge, discomfort
Functional Urinary Incontinence
The inability of a usually continent person to reach toilet in time to avoid unintentional loss of urine
Functional Urinary incontinence r/t
cognitive disorders, neuromuscular limitations, impairing mobility, environmental barrier to toileting
Total Urinary Incontinence
continuous urine output with no identifiable voiding reflex
Total Urinary Incontinence r/t
neurogenic disorder
Urinary Retention
Incomplete emptying of the bladder r/t bladder outlet obstruction, prostate cancer, constipation, benign prostatic hypertrophy
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
Defining characteristics of urinary retention
residual urine greater than 150-250mL, urgency, freq, nocturia, overflow
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
Outcome for altered urinary elimination
achieve bladder control, restore normal elimination pattern
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
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
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
Signs of UTI
frequency, urgency, dysuria
Main functions of large intestine
absorption of h20 and nutrients
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
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
Toddler Bowel
some control, toilet training begins when aware of discomfort of dirty diaper and recognition to defecate
School Age Bowel
May delay defecation because of an activity
Older Adults
Constipation is a problem, evaluate any complaint of constipation
Normal Stool Color
Brown-Yellow
Normal Stool Consistency
formed, soft, semi-solid, moist
Normal Stool Shape
cylindrical
Constipated Stool Color
dark
Constipated Stool Consistency
small, dry, hard
Constipated Stool Shape
pellet
Constipated Stool Amount/freq
fewer than 3 times a week in small amounts
Diarrhea Color
variable
Diarrhea Consistency
liquid
Diarrhea Shape
unformed
Diarrhea freq
increased
Nursing History Assessment Bowel
defecation pattern, characteristics of stool, fecal elimination problem identification, factors influencing elimination
How much fiber per day?
20-35grams
Nursing measures that promote normal/regular defecation
privacy, timing, nutrition, fluids, exercise, positioning
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
Causes of Fecal Impaction
Prolonged retention and accumulation of fecal matter caused by poor defecation habits, history of constipation, and certain medications like barium
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
Causes of Diarrhea
psychological stress, medications, allergies, food/fluid intolerances, diseases of the colon, clostridium difficile-associated disease and surgical operations
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
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
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.
Common Bowel Medications
Ioperamide, Bisacodyl, Docusate, Psyllium hydrophilic mucilloid, Magnesium hydroxide
Loperadmide (Imodium)
antidiarrheal agent
Bisacodyl (Dulcolax)
stimulant laxative
Docusate Sodium (Colace)
stool softener
Psyllium hydrophilic mucilloid (metamucil)
bulk laxative
Magnesium Hydroxide (Milk of Magnesia)
saline cathartic, antacid
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.
Cathartic
purgative; medicine that causes the bowels to empty; ADJ.
Defecation
the elimination of fecal waste through the anus
Diarrhea
frequent discharge of liquid stool
Enema
injection of a liquid through the anus to stimulate evacuation
Feces
solid excretory product evacuated from the bowels
Flatus
gas expelled through the anus
Hemorrhoids
swollen, twisted, varicose veins in the rectal region
Impaction
a disorder in which feces are impacted in the lower colon
Peristalsis
the process of wave-like muscle contractions of the alimentary tract that moves food along
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.
Stool
excreted feces
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
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
When does planning happen?
Begins with the first contact and continues until the nurse-client relationship ends
Client Goal
Broad statement about an observable client condition achieved by implementing nursing interventions.
Outcome Criteria
Specific criteria that focus on observable/measurable results of health care team activities. Stepping stones to reaching the outcome.
Step: Prioritize problems/diagnoses
Choose nursing diagnoses using maslow’s and sort them by high, intermediate, low priority
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)
SMART
specific, measurable, appropriate, realistic, timely
TEA
Time frame, expected behavior, action verb
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
Straight Catheter
a catheter that drains the bladder and then is removed
Lithotomy position
a position lying on your back with knees bent and thighs apart
Clean Catch Urine
Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI
Midstream urine
Urine specimen collected when a urine culture is ordered to identify microorganisms cause UTI
Urinalysis
To determine urine composition and possible abnormal components or infection
Urine for culture and sensitivity
Determine the presence of microorganisms, the type of organisms, and the antibiotics to which the organisms are sensitive
