Module II - Units C, D, E

Procedure used to see inside bladder, urethra, ureters

Hollow tube (cystoscope) equipped with a lens

Inserted into urethra and slowly advanced into bladder

Examines the lining of bladder & urethra

Investigate causes of bladder signs and symptoms such as

• Blood
• in the urine         
• Frequent UTIs
• Incontinence                
• dysuria
• Overactive bladder

• To Diagnosis Diseases Such As
• Bladder cancer, stones
• Bladder inflammation (cystitis)

• Looking for Enlarged Prostate
• (benign prostatic hyperplasia)
• Narrowing of the urethra where it passes through the prostate gland 

Sometimes used to remove small bladder tumors

• Painful urination
• Only a little comes out and it burns

Continued incontinence of urine past the age of toilet training

Occasional daytime incontinence of urine in children is not concerning

• Bed wetting at night
• Subsides by 6 years old

Urination at night

Diminished ability of the kidneys to concentrate urine

• Blood in urine
• aka Presence of red blood cells in urine

Pink, red or cola-colored but can be microscopic

Takes very little blood to produce the color

Usually isn't painful unless it is the passing of blood clots in urine

• Common Causes
• UTI
• Inherited disorder (sickle cell, Alport Sydrome)
• Kidney infection, disease, or injury
• Bladder or kidney stone
• Enlarged prostate

A sign of advanced kidney, bladder or prostate cancer

Medications (some chemo drugs, antibiotics, aspirin)

Difficulty starting or maintaining a urine stream

Most common in older men with an enlarged prostate gland

Exercises used to strengthen perineal muscle tone 

Target inner muscles that lie under & support the bladder

Same muscles that contract to stop urination midstream / control defecation

Hold for 10 seconds / relax for 10 seconds

The process of emptying the bladder

Nerve centers for it are in brain & spinal cord

Involuntary reflex but control can be learned

Voluntary control develops as higher nerve centers develop in infancy

aka Urination, Voiding

Oliguria

Low urine output

• Adult
• Output (less than 400ml per day)

• Infant
• Output (less than 1 mL/kg/h)

• Child
• Output (less than 0.5 mL/kg/h)

Clinical hallmark of renal failure

Test that measures amount of urine left in the bladder after urination

Measured by draining the bladder with a catheter

Can sometimes be measured with ultrasound

Excessive volume of urination for an adult

Greater than 2.5 Liters / day

• Common & Not so Common Causes
• Diabetes (mellitus, insipidus)
• Drinking lots of water, coffee, alcohol)
• Diuretics or lithium medication
• Sickle Cell Anemia
• Ph of blood too high or low
• Kidney failure

Physical movement or activity (coughing, sneezing, running, heavy lifting)

Puts pressure (stress) on bladder

NOT related to psychological stress

Involuntary loss of urine

• Common in women
• (urethra shorter than men)

Coughing & sneezing Increases abdominal pressure causing involuntary escape of urine

• Inability to empty the bladder completely
• Can be acute or chronic

Acute is considered a medical emergency (cannot empty at all)

• Chronic
• retention means can urinate but not completely

Causes

Obstruction of the Urethra due to

Benign prostatic hyperplasia (BPH) aka Enlarged Prostate

Urethral stricture due to inflammation, scarring from surgery

Urinary tract stones

• Cystocele
• (bulging of the bladder into the vagina)

• Rectocele
• (bulging of the rectum into the vagina)

Constipation

Hard stools in the rectum push against the bladder & urethra



Nerve damage or problems from

Vaginal childbirth

MS, stroke, diabetes

Brain or spinal cord infections or injuries

Medications (antihistamines, anticholinergics, tricyclic antidepressants)  

Tumors & cancers

Treatment for patients with history of chronic constipation

Manipulate factors within patient’s control to produce soft, formed stool regularly

Goal is to not need laxatives

• Factors
• include: fluid intake, food, exercise, timing

Used interchangeably but Cathartics exert a stronger effect

• Endoscopic examination of the large bowel and the distal part of the small bowel           
• Uses CCD camera or a fiber optic camera on a flexible tube

Tube is passed through the anus

Provides visual diagnosis (e.g. ulceration, polyps)

Can be used for biopsy or removal of suspected colorectal cancer lesions

Dry, hard, stools that are difficult or incomplete to pass

Having less than 3 bowel movements in a week

The passage of three or more loose stools a day

Cramps, nausea, vomiting, & blood in stools may occur

Protective response to irritation in intestinal tract

Fluids & electrolytes are lost quickly

To “look inside” the body for using an endoscope

Examines interior of a hollow organ or cavity of the body

Are inserted directly into the organ

Buildup of stool in the colon

Intenstinal gas

Abnormal distended rectal veins

Vertical folds in rectum (three transverse) each contain an artery & vein

Blood in stool that is hidden in the specimen and cannot be seen on gross examination

Contractions of the circular & longitudinal muscles of the intestine

Moves waste products along length of intestine continuously

Occurs every 3 to 12 minutes

Minimally invasive medical examination of the large intestine from the rectum through the last part of the colon

Two Types

• Flexible sigmoidoscopy, which uses a
• flexible endoscope (preferred procedure)

• Rigid sigmoidoscopy, which uses a rigid
• device

Similar to, but not the same as, a colonoscopy

Only examines up to the sigmoid (most distal part of the colon)

Verses a colonoscopy examines the whole large bowel

Moderately forceful attempted exhalation against a closed airway

Done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon

Find avideo on YouTube

Used for rectal examination, treatments and enemas

Patient lie on left side

Left hip and lower extremity straight

Right hip and knee bent

• Also
• called lateral recumbent position

Frequency

Glycoseuria

Proteinuria

Pyuria

Suppression

62-120 ml

Urgency

Incontinence

How clear urine is

Urine is clear when fresh but becomes cloudy as it stands and cools

Urine that is cloudy fresh is abnormal

Could be due to the urine containing the following contents

Vaginal discharge or sperm

White or red blood cells

Bacteria

6.0 

But can range from 4.6 – 8

alkaline

a. Acidic

b. Alkaline

Normal Specific Gravity of urine is 1.015-1.025

• a. dehydration
• b. hydration

Concentrated means higher than normal range

Diluted means lower than normal range

Urea, uric acid, creatinine, urine pigments, nitrogen

Ammonium, electrolytes

Blood, puss, albumin, ketones, glucose, bile, bacteria

• Direct visual of bladder, urethra
• Pre-op consent, can
• have fluids in morning but no solid food

Sedated & ordinary painless

Examines kidneys with IV contrast dye

Rules out renal dysfunction or impairment

Urge Incontinence (Urgency)

Mixed Incontinence

Overflow Incontinence

Functional Incontinence

Transience Incontinence

Reflex Incontinence

Total Incontinence

• Soft pliable sheath of silicone applied externally to penis (self-adhesive) connected
• to bag

Used when voluntary control of urination not possible for males

An alternative to indwelling catheter

Blood that is hidden in the stool and cannot be seen on gross examination

• May be performed by nurse at bedside
• or by patient at home

• The direct visual examination of body organs
• Uses a fiber-optic endoscope that transmits light

• Esophagogastroduodenoscopy
• (visualizes esophagus, stomach, & duodenum)

• Colonoscopy
• (Visualizes large intestine from anus to ileocecal valve)

• Sigmoidoscopy
• (Visualizes sigmoid colon, rectum, & anal canal)

Body Mechanics

Incomplete expansion / collapse of lung tissue due to areas of lung tissue not used

Decrease in muscle size                                   

Happens rapidly in patients confined to a bed

Consolidation & immobilization of a joint

Increasesprocess of osteoporosis (bone de-mineralization)

Phenomenon where one amount of REM sleep remain constant over time

(If missing REM sleep for a few nights, will spent more time in  REM sleep on successive nights)

Sleep disorders characterized by insomnia or excessive sleepiness

Type of Dyssomnia

Difficulty of falling asleep, intermittent sleep, or early awakening

More common of all sleep disorders

More in women (pre & post menopause), 60+, depression

Can be acute or chronic

Sleep hygiene (non-pharmacologic treatments) may help

• Causes
• Stress,
• psychiatric disorders
• obesity
• caffeine use
• diabetes

Type of Dyssomnia

• Excessive sleep (particularly during the day)
• Fall asleep during work, eating, etc.
• Napping does not relieve symptoms
• Feel disoriented, irritated when awake

• Causes
• Sleep apnea
• alcohol & substance abuse
• head trauma,                                                         
• Depression
• Obesity
• CNS disorders
• Medication side-effects

Type of Dyssomnia

Neurological disorder causing uncontrolled desire to sleep

Patients fall asleep standing up, driving, mid-conversion, swimming,

Fall asleep quickly & hard to wake up

Treated with medication

Driving restrictions are placed due safety of patient

Absence of breathing (apnea) or diminished breathing efforts (hypopnea)  during sleep between snoring intervals

Breathing ceases for 10 seconds to 2 minutes 

• Causes
• irregular pulse, increase BP, irregular pulse

Oxygen levels in blood drop

Excessive sleepiness commonly reported

• More common in
• older, heavier,
• possessing thick short necks

airway blocked

Collapsed hypo-pharynx, enlarged tonsils, deviated septum

• Treatments
• CPAP machine
• Surgery (removing tonsils, & tissues)

Inability to lie still without unpleasant creeping, crawling, tingling sensation in legs

Associated with iron deficiency (correlation cannot be explained)

OCT meds like antihistamines exacerbate symptoms

• URGE acronym used
• Urge to move legs
• Rest induced
• Gets better with activity
• Evening symptoms more severe

Decrease in amount, consistency, or quality of sleep

Decreased NREM & REM sleep

Damaging mental & physically

Parasomnias

• Somnambulism
• (Sleepwalking)

Sleep Talking

Night terrors (screaming due to perceived threat)

Bruxism (grinding teeth during sleep)

Enuresis (urinating during sleep), usually outgrown by adulthood

Sleep Eating Disorder (Eating during sleep and not remembering)

Somnambulism

Observed in 10%-20% of chronic insomniacs

Muscle contractions resulting in jerking of legs during sleep

Contractions may arouse sleeper, contributing to insomnia

Atony

Inability to lift the front part of the foot

This causes the toes to drag along the ground while walking

Stems from weakness or paralysis of the muscles that lift the foot

Tonus

• Could come from the cancer (tumor infiltrations) or the treatments     
• Hormone changes, skin, nerve changes

Conscious Sedation

aka Procedural sedation & analgesia

pain threshold

Pain that is felt in location other than the site of the stimulus

• Example: Ischemia brought on by MI
• Pain is felt in neck, shoulders, and back
• Location of stimulus is in the chest

Pain Tolerance

aka "endogenous morphine"

Endogenous opioid inhibitory neuropeptides

Produced by the central nervous system and pituitary gland.

• Acute Pain
• Rapid in onset varying in intensity from mild to severe

Protective in nature to alert of damage or disease

Ends when healing is complete

Cut finger, sore throat, surgical wounds

• Chronic Pain
• Lasts beyond the normal healing period

Can be limited, intermittent, or persistent

Difficult for patient to describe and for nurse to assess

Often perceived as meaningless causing emotional issues for patient

• Remission
• Disease is present but individual does not have symptoms

• Exacerbation
• When symptoms reappear

Involves skin or subcutaneous tissue

Example: Paper cut, skinning of knee

Originates in tendons, ligaments, bones, vessels, & nerves

Diffuses and scatters from origin

Example: Ankle sprain (pressure on bone & damage to tissue)

Originates in body organs in thorax, cranium, and abdomen

Poorly localized

Organs become distended, ischemic, or inflamed

Occurs due to organs stretching abnormally

Example:Appendicitis

• Pain resulting in PNS & CNS system damage
• Can be short duration or lingering          Described as burning or stabbing        

Diabetic Neuropathy, carpel tunnel

Examples listed on table 35-1 on pg. 1114

Intractable (Pain)

Feel pain in amputated limb where receptors and nerves are gone

Location & presence of pain is clear to patient

Also called Phantom Limb Pain

Psychogenic Pain

Acupressure

Analgesic

• acetaminophen, NSAIDs, COX-2 Inhibitors
• Celecoxib (Celebrex)

for mild to moderate pain

Analgesic that attaches to opioid receptors in the brain

Nausea, constipation, & sedation (drowsy)

Feared respiratory depression (keep eye on patients who are on it)

• Enzymes that promote binding at site may
• be missing in some individuals          

May explain why responses to opioid meds vary in some patients

• Tolerance
• Body becomes accustomed to opioid & require higher dose for pain relief

• Physical Dependence
• Body is physiologically accustomed to opiod
• Suffers withdrawal symptoms if suddenly removed or dose decreases

• Addiction
• Pattern of compulsive opioid
• No longer using it for pain
• Craving, compulsive use, lack of control over use
• Continuing use despite harm

Used for other purposes than pain

Used to enhance effects if opioids or reduce side effects

• Lessen anxiety about pain experience      
•           
• Examples
• anti-depressants,
• anti-convulsion, corticosteroids
• Atropine

Breakthrough Pain (BTP)

Computerized portable infusion pump with bag or syringe prefilled with opioid

Lock-out-interval prevents over medication

Candidates for PCA must be alert & capable with no risk of over-sedation

• Gives patients a sense of control
• Studies find that patients use less

Catheter inserted into mid-lumbar region, b/t walls of vertebral canal & dura matter

• Provide relief during / during
• Immediate post-op
• (thoracic, abdominal, & vascular, ortho surgery)

• Children with terminal cancer
• Chronic pain situations