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Fundamentals Exam 5
Terms in this set (78)
Excrete waste in the form of urine. Removes urea, creatinine, uric acid. Maintains and regulates fluid balance. You can live with only one.
Small tubes that extend from the kidneys to the bladder (holding tank). Urine flows from the kidneys down to the ureters to the bladder
Holding tank. Usually feel the urge to void when 150-250mL of urine is in the bladder. Can harbor bacterial growth if urine is left to sit in the bladder
greater than normal urinary elimination. May accompany minor dietary variations (coffee, tea, some medications).
Inadequate elimination of urine
Absence of urine
Difficult or painful urination
Action of urinating
Developmental considerations, food and fluid intake, psychological variables, activity and muscle tone, pathological conditions, and medications
Developmental Considerations: Children (urinary)
Children: Toilet Training (2-3 years old)
Should not occur until the child can hold urine for 2hrs, recognize the feeling of bladder fullness, communicating the need to void, control urination until seated on the toilet, and desires to gain control.
(Regression of toilet skills can occur during hospitalization, expected and short lived)
Developmental Considerations: Aging (urinary)
Increased frequency, nocturia, urine retention and stasis, voluntary control affected by physical problems
Frequent nighttime urination
= red urine
= pale yellow urine
Pyridium (analgesic for urinary pain relief)
= orange to orange-red urine
Antidepressants (Amitriptyline or B-Complex vitamins)
= green or blue-green urine
= brown or black urine
Glucose in the urine.
-Obtain a finger stick for blood glucose levels
I&O may be important going forward
Blood in the urine (urine sample is reddish-brown)
Urine appears dark amber in color
Infection and Stasis
Causes urine to appear cloudy
Pus in the urine
Protein in the urine
Assess data about voiding problems, habits, past history of problems.
Preform a physical assessment of the bladder, urethral meatus (if indicated) assessment of skin integrity and hydration, and examine the urine.
Correlation of findings with results of procedures and diagnostics tests (X-ray, cystoscopy, retrograde pyelogram, renal ultrasound, CT, intravenous pyelogram.
Physical Assessment: Urinary Bladder
Palpate and percuss bladder or use bedside scanner.
When a bladder is distended with urine, it rises just above the symphysis pubis and may reach just below the umbilicus. Other choices are anatomically incorrect when assessing a distended bladder
Physical Assessment: Kidneys
Physical Assessment: Urethral Orifice
Inspect for signs of infection, discharge, and odor.
Physical Assessment: Skin
Assess for color, texture, turgor, excretion of wastes.
Healthy skin should be moist, and non-inflammed with no discharge present. Presence of reddened perineal skin is an abnormal finding
May be the result of those who view themselves as old, powerless, and/or neglected. May cease to value voluntary control over urination and simply find toileting too much bother no matter the setting.
Can lead to:
-Degenerative joint problems
-Alterations in thought process
In elderly, they may ignore or forget that they have an urge to use the bathroom which contributes to their incontinence. By completing habit training and taking them to the bathroom at regular intervals, it may decrease their episodes of incontinence.
Caused by weakened pelvic floor muscles, from age or child birthing (Pregnancy!!). Also, when increased pressure is in the abdominal cavity (jumping, sneezing, or coughing) there is involuntary expression of urine
Appears suddenly and lasts for 6 months or less
Urine loss with features of two or more types of incontinence
Overdistention and overflow of bladder
Caused by factors outside the urinary tract
Emptying of the bladder without the sensation of the need to void
Continuous, unpredictable loss of urine
Contraction and relaxation of the pelvic floor muscles to improve urethral and rectal sphincter function
Daily recommended fluid intake
1500-2000mL or 6-8oz daily (may be decreased at nighttime to decrease nocturia)
Measuring Urine Output
-Ask patient to void into bedpan, urinal, or specimen container in bed or bathroom.
-Put gloves on and pour urine into appropriate measuring device.
-Place calibrated container on flat surface and read at eye level.
-Note amount of urine voided and record on appropriate form.
-Discard urine in toilet unless specimen is needed.
Normal urine output
Minimal urine output
A conservation of fluid by the body during states of under hydration, fever, and diaphoresis results in the production of concentrated urine that is dark in color
Can cause ototoxicity if the patient is having decreased hearing due to their Lasix. If it is causing ototoxicity, then you should hold the next dose and call the physician immediately. The damage can be reversible, but the physician must be aware.
-Clean-catch or midstream specimens
-Sterile specimens from indwelling catheter
-24-hour urine specimen
-Specimens from infants and children
-Point-or-care urine testing
Promoting and Maintaining Normal Urination
Maintaining normal voiding habits, promoting fluid intake, strengthening muscle tone, assisting with toileting, schedule, privacy, position, hygiene.
Urinary Tract Infection (UTI)
Characterized by cloudy, foul-smelling, burning on urination, increased urgency, and frequency of urination.
- Most normal flora in the large intestine
- Most common cause of UTI's due to the contamination from poor or improper hygiene.
Women are more prone to UTI's because
- Their urethra is shorter
- Easier mechanism for bacteria to ascend up the urinary tract
- The distance from the anus to the urethra is a shorter distance for contamination to occur.
Patients at risk for UTI's
- Sexually active women
- Women who use diaphragms for contraception
- Postmenopausal women
- Individuals with indwelling urinary catheter
- Individuals with diabetes mellitus
- Elderly people
Reducing Risk for UTI
- Void after sexual intercourse
- Taking frequent bubble baths can cause a UTI
- Wiping front to back
- Snug fitting pants or underwear increases the risk of a UTI
- Bubble baths, using harsh soaps, and wearing tight-fitting pants irritates the urethra
Reasons for Catherization
- Relieving urinary retention
- Prolonged patient immobilization
- Obtaining a sterile urine specimen when a patient is unable to void
- Accurate measurement of urinary output in critically ill patients
- Assisting in healing open sacral or perineal wounds in incontinent patients
- Emptying the bladder before, during, and after surgical procedures and before certain diagnostic examinations
- Providing improved comfort for end-of-life care
Types of Catheters
- ALWAYS ensure you close the door and curtain
- Explain the procedure and rationale (clients who understand the procedure are more apt to relax)
- Nurses are responsible for preparing the client and preforming aftercare
- Demonstrate empathy and always use caring supportive statements
- Reduce anxiety
Patient Education for Urinary Diversion
- Explain reason for diversion and rationale for treatment
- Demonstrate effective self-care behaviors
- Describe follow-up care and support resources
- Report where supplies may be obtained in the community
- Verbalize related fears and concerns
- Demonstrate a positive body image
- Uses machine
- A vascular access device is implanted
- Fistula or graft
- feel the "thrill"
- Uses blood vessels in abdominal lining (peritoneum)
- Dialysate wash
- "Dwell time"
- Catheter in abdomen into the peritoneal cavity
A nurse is caring for a client who is being treated for a bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the clients condition?
Use of an indwelling urinary catheter leads to the loss of bladder tone. (T/F)
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?
Decreased and highly concentrated
Overflow incontinence is characterized by: (SATA)
- Leaking/dribbling due to inability to empty bladder fully
- Associated with neurogenic bladder due to the inability to sense when bladder is full
- Secrets enzymes that digest proteins and carbohydrates.
- Digestive juices from the liver and pancreas enter the small intestine through a small opening called the duodenum.
- Responsible for digestion of food and absorption of nutrients into the bloodstream
- Primary organ of bowel elimination
- Extends from the ileocecal valve to the anus.
- Absorbs water
- Expels feces from the body
Process of Peristalsis
-Peristalsis is under control of the nervous system.
-Contractions occur every 3 to 12 minutes.
-Mass peristalsis sweeps occur one to four times each 24-hour period.
-One third to one half of food waste is excreted in stool within 24 hours.
Variables Influencing Bowel Elimination
- Developmental considerations
- Daily patterns
- Food and fluid
- Activity and muscle tone
- Psychological variables
- Pathologic conditions
- Diagnostic studies
- Surgery and anesthesia
Developmental Considerations: Infants
Characteristics of stool and frequency depend on formula or breast feedings
Developmental Considerations: Toddlers
Physiologic maturity is first priority for bowel training
Developmental Considerations: Children, Adolescents, Adults
Defecation patterns vary in quantity, frequency, and rhythmicity
Developmental Considerations: Older Adults
Constipation is often a chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes
Foods Affecting Bowel Elimination
- Constipating foods: cheese, lean meat, eggs, pasta
- Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee
- Gas-producing foods: onions, cabbage, beans, cauliflower
Aspirin / Anticoagulants
= pink to red to black stool
Bismuth subsalicylate (Pepto-Bismol) and Iron Salts
= Black Stool
= white discoloration or speckling in the stool
= Green-gray colored stool
Occasional use of laxatives is not harmful for most people, but clients should not become dependent on them.
- Habitual use of laxatives is the most common cause of chronic constipation
Physical Assessment of the Abdomen
inspection, auscultation, percussion, palpation
Inspection of Abdomen
Observe contour, any masses, scars, or distention
Auscultation of Abdomen
- Listen for bowel sounds in all quadrants
- Note frequency and character, audible clicks, and flatus.
- Describe bowel sounds as hypoactive, hyperactive, absent or infrequent.
Percussion and Palpation of the Abdomen
Preformed by advanced practice professionals
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