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What is the process of urination?
The kidneys remove wastes from the blood to form urine. Ureters transport urine from the kidney to the bladder. The bladder holds urine until the urge to urinate develops. Unine then exits the bladder through the urethra and passes out of the body through the urethral meatus.
What conditions affect urine volume and quality? (prerenal, renal, or postrenal)
- Acute and reversible like UTI
- Chronic an irreversible like slow, progressive development of renal dysfunction
- Disease conditions
- Sociocultural factors
- Psychological factors
- Fluid balance
- Diagnostic procedures
- Medications (including anesthesia)
- Prerenal: cause decreased blood flow to and through kidney
- Renal: disease conditions of renal tissue
- Postrenal: obstruction in the lower urinary tract that prevents urine flow from kidneys
- Conditions of lower urinary tract, including narrowing of urethra, altered innervation of bladder, or weakened pelvic and /or perineal muscle, affect urinary elimination
How do different disease processes affect or cause urinary elimination problems?
- Diabetes mellitus & neuromuscular diseases like multiple sclerosis: cause changes in nerve function that lead to possible loss of bladder tone, reduces sensation of bladder fullness or inability to inhibit bladder contractions
- Benign prostate hyperplasia (BPH): prone to urinary retention & incontinence
- Cognitive impairment like Alzheimers: lose ability to sense full bladder or unable to recall procedure for voiding
- Diseases that slow or hinder physical activity: interfere with ability to void
- Degenerative joint disease and Parkinsonism: make it difficult to reach & use toilet
- Diseases that cause irreversible kidney damage: result in end-stage-renal disease (ESRD)=resulting in uremic syndrome= increase in nitrogenous wastes in blood, HA, coma & convulsions
- Decreased blood flow
- Diabetes mellitus
- Multiple sclerosis
- Benign Prostatic hyperplasia (BPH)
- Alzheimer's disease
- diabetes, multiple sclerosis, hyperplasia= increase in cells; at the prostate worried about prostate cancer; benign prostatic hyperplasia= noncancerous increase in prostate
How would the nurse obtain a history for a patient with urinary elimination problems?
- Nature of problem: type of prob, describe recent day/night w/prob, is pattern constant
- S&S: urgency, loss of urine w/coughing, leakage
- Onset & duration: when noticed, how long
- Severity: how many times, how does pattern compare w/past, what is done when symptoms occur
- Predisposing factor: vaginal birth? How many? What doing at time it occurs, do symptoms increase after eating/drinking caffeine/alcohol, meds? Physically ill?
- Effect on pt: life? Change usual activities, sought any medical help?
What nursing diagnoses would be appropriate for patients with alterations in urinary elimination?
- Social isolation
- Disturbed body image
- Urinary incontinence (functional, stress, urge, overflow)
- Pain (acute, chronic)
- Risk for infection
- Toileting self-care deficit
- Impaired skin integrity
- Impaired urinary elimination
- Urinary retention
How would the nurse obtain urine specimens correctly?
- RANDOM OR ROUTINE URINALYSIS: COLLECT DURING NORMAL VOIDING OR FROM AN INDWELLING CATHETER OR URINARY DIVERSION COLLECTION BAG. DO NOT COLLECT FROM AN INDWELLING CATHETER DRAINAGE BAG.
- CLEAN-VOIDED OR MIDSTREAM (CULTURE AND SENSITIVITY): CLEAN AREA 3 TIMES, INITIATE STREAM, PASS CONTAINER INTO STREAM AND COLLECT IN A STERILE SPECIMAN CUP.
- STERILE SPECIMEN (CULTURE AND SENSITIVITY): IF THE PATIENT HAS AN INDWELLING CATHETER, COLLECT A STERILE SPECIMEN BY USING ASEPTIC TECHNIQUE THROUGH THE SPECIAL SAMPLING PORT FOUND ON THE SIDE OF THE CATHETER. CLAMP THE TUBING BELOW THE PORT, ALLOWING FRESH, UNCONTAMINATED URINE TO COLLECT IN THE TUBE. AFTER WIPING THE PORT WITH AN ANTIMICROBIAL SWAB, INSERT A STERIL SYRINGE HUB AND WITHDRAWAL AT LEAST 3 TO 5 mL OF URINE. USING ASEPTIC TECHNIQUE, TRANSFER THE URINE TO A STERILE CONTAINER.
- TIME URINE SPECIMENS FOR MEASURING LEVELS OF ADRENOCORTICAL STEROIDS OR HORMONES, CREATININE CLEARANCE, OR PROTEIN QUANTITY TESTS: TIME REQUIRED MAY BE 2-, 12-, 24-HOUR COLLECTIONS. THE TIMED PERIOD BEGINS AFTER THE PATIENT URINATED AND ENDS WITH A FINAL VOIDING AT THE END OF THE TIME PERIOD. THE PATIENT VOIDS INTO A CLEAN RECEPTACLE, AND THE URINE IS TRANSFERED TO THE SPECIAL COLLECTION CONTAINER, WHICH OFTEN CONTAINS SPECIAL PRESERVATIVES. EACH SPECIMAN MUST BE FREE OF FECES AND TOILET TISSUE. MISSED SPECIMENS MAKE THE WHOLE COLLECTION INACCURATE. CHECK WITH AGENCY POLICY AND THE LABORATORY FOR SPECIFIC INSTRUCTIONS
What are the characteristics of normal and abnormal urine?
- pH (4.6-8.0)
- pH OF URINE INDICATES ACID-BASE BALANCE. AN ACID PH HELPS PROTECT AGAINST BACTERIAL GROWTH. URINE THAT STANDS FOR SEVERAL HOURS BECOMES ALKALINE
- pale yellow, straw colored or amber color: normal, fresh-voided specimen
- darker than normal color: scanty or concentrated
- lighter than normal color: excessive and diluted
- aromatic odor: normal
- ammonia odor: standing (from bacterial action)
- sweet odor: high in glucose
- fetid odor: heavily infected
- clear, transluscent turbidity: normal
- cloudy turbidity: standing, abnormal
- 6.0 pH: normal
- 1.015 - 1.025: specific gravity: normal; high: concentrated, dehydration, low: dilute, overhydration (specific gravity; density of urine compared to density of water)
- abnormal urine constituents: blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria and bile
What are common types of urinary alterations based on symptoms?
- FUNCTIONAL: LOSS OF URINE CAUSED BY FACTORS OUTSIDE THE URINARY TRACT THAT INTERFERE WITH THE ABILITY TO RESPOND IN A SOCIALLY APPROPRIATE WAY TO THE URGE TO VOID.
- RELEVANT FACTORS: ENVIRONMENTAL BARRIERS; SENSORY, COGNITIVE, AND MOBILITY ISSUES
- S&S: URGE TO VOID THAT CAUSES LOSS OF URINE BEFORE REACHING APPROPRIATE RECEPTACLE
- INTERVENTIONS: CLOTHING MODIFICATIONS, ENVIRONMENTAL ALTERATIONS. SCHEDULED TOILETING, ABSORBENT PRODUCTS
- STRESS: INVOLUNTARY LEAKAGE OF URINE DURING INCREASED ABDOMINAL PRESSURE IN THE ABSENCE OF BLADDER MUSCLE CONTRACTION.
- S/S: LOSS OF URINE WITH INCREASED INTRAABDOMINAL PRESSURE (COUGHING, LAUGHING, SNEEZING, OR LIFTING WITH A FULL BLADDER)
- INTERVENTIONS: PELVIC FLOOR EXERCISES, SURGICAL INTERVENTIONS, BIOFEEDBACK, ELECTRICAL STIMULATION, ABSORBENT PRODUCTS
- URGE: INVOLUNTARY PASSAGE OF URINE AFTER A STRONG SENSE OF URGENCY TO VOID
- S/S: URINARY URGENCY, OFTEN WITH FREQUENCY (MORE OFTEN THAN EVERY 2 HOURS); BLADDER SPASM OR CONTRACTION.
- INTERVENTIONS: ANTIMUSCARINIC AGENTS, BEHAVIORAL INTERVENTIONS, BIOFEEDBACK, BLADDER RETRAINING, PELVIC FLOOR EXERCISES, LIFESTYLE MODIFICATIONS (SMOKING CESSATION, EIGHT LOSS AND FLUID MODIFICATIONS), ABSORBENT PRODUCTS.
- MIXED: COMBINATION OF URGE AND STRESS URINARY INCONTINENCE SIGNS AND SYMPTOMS
- S/S: COMBINATION OF URGE AND STRESS SYMPTOMS
- INTERVENTIONS: MAIN TREATMENTS USUALLY BASED ON SYMPTOMS THAT ARE MOST BOTHERSOME TO PATIENT
- OVERFLOW INCONTINENCE: INVOLUNTARY LOSS OF URINE AT INTERVALS WITHOUT SENSATION OF URGE TO VOID.
- RELEVANT FACTORS: SPINAL CORD DYSFUNCTION--LOSS OF CEREBRAL AWARENESS OR IMPIRMENT OF REFLEX ARC
- S/S: LACK OF URGE TO VOID, AWARENESS OF BLADDER FILLING, REFLEX EMPTYING WHEN CERTAIN VOLUME REACHED.
- INTERVENTIONS: INTERMITTENT CATHETERIZATION, CONDOM CATHETER, CREDE'S METHOD
- HYPERACTIVE/OVERACTIVE BLADDER: URINARY URGENCY THAT IS ASSOCIATED WITH URINARY FREQUENCY AND NOCTURIA
- S/S: SUDDEN COMPELLING DESIRE TO URINATE THAT IS DIFFICULT TO DETER.
- INTERVENTIONS: PELVIC FLOOR EXERCISES, INTAKE OF 1.5-2L OF FLUID A DAY, LIMIT CARBONATED AND CAFFEINATED BEVERAGES, BLADDER TRAINING, BIOFEEDBACK
What labs are utilized to evaluate urine?
- ROUTINE URINALYSIS MEASUREMENT AND NORMAL VALUES :
- PROTEIN (NONE OR UP TO 8 mg/100mL: NORMALLY PROTEIN IS NOT PRESENT IN URINE. IT IS COMMON IN RENAL DISEASE BECAUSE DAMAGE TO GLOMERULI OR TUBULES ALLOWS IT TO ENTER URINE.
- GLUCOSE (NONE)
- KETONES (NONE)
- BLOOD (NONE)
- SPECIFIC GRAVITY (1.0053-1.030)
- MICROSCOPIC EXAMINATION:
- RBCs (UP TO 2)
- WBCs (0-4 PER LOW-POWER FIELD)
- BACTERIA (NONE)
- CASTS (NONE)
- CRYSTALS (NONE)
What diagnostic examinations could be performed to evaluate the renal system?
- ABDOMINAL ROENTGENOGRAM (KUB)
- INTRAVENOUS PYELOGRAM (IVP)
- RENAL ULTRASOUND
- BLADDER ULTRASOUND
- URODYNAMIC TESTING (UROFLOWMETRY)
- ENDOSCOPY-CYSTOSCOPY (INVASIVE)
- ARTERIOGRAM (ANGIOGRAPHY)
What nursing implications are involved with common diagnostic tests of the urinary system?
- - Explain the procedure to the patient/client.
- - Collection of specimens in appropriate containers, at the correct time, and in the correct manner.
- - Label all specimens correctly.
- - Instruction and use of infection control measures.
- - Obtaining consent.
- - Assessing for allergies to dyes, etc used in testing the urinary system.
- - Ensuring patient/client safety during testing as needed.
- - Preventing complications
What nursing measures promote normal micturition and reduce episodes of incontinence?
- completely empty bladder
- prevent infection
- stimulate micturition reflex
- maintain elimination habits
- maintain fluids
When would urinary catheterization be indicated?
- 1. patient unable to void (not incontinence)
- 2. output monitoring
- 3. sometimes to keep open wounds and ulcers clean
- Indications for intermittent catheter:
- Relief of discomfort from bladder distention
- Sterile urine specimen collection
- Assessment of residual urine
- Long-term management of spinal cord injuries, neuromuscular degeneration or incompetent bladders
- Indications of Short-term Indwelling catheter:
- Urethral obstruction
- Surgical repair of urethra
- Prevention of urethral obstruction caused by blood clots
- Measurement of urinary output in critically ill
- Continuous or intermittent bladder irrigation
- Indication for Long-term Indwelling catheter:
- Severe urinary retention w/recurrent UTI
- Skin rashes, ulcers or wound irritate by contact w/urine
- Terminal illness when bed linen changes are painful
How would the nurse insert a urinary catheter correctly?
What can the nurse do to reduce urinary tract infections?
- Good hygiene
- Women-wipe front to back
- Void after intercourse
- Prevent partial voiding
- 1200-15--ml of fluid per day-fluch
- avoid excessive soaping or bubble baths, wear cotton underwear, fluids high in acid ash-apple/cran juice.
- caths. box 45-10 pg 1063
- -use caths only when necessary and remove asap
- -use non-invasive interventions
How would the nurse irrigate a urinary catheter correctly?
- Done for UTI or after prostatectomy
- Assess need for irrigation
- Check order: type (continuous, intermittent); type of catheter (single lumen= open intermittent only; double lumen= 1 lumen to inflate balloon, 1 for urine flow; triple= 1 for balloon, 1 for irrigation solution, 1 for urine flow)
- Hand hygiene
- Expose only area needed
- Position pt dorsal recumbent or supine
- Closed intermittent:
- Pour px sterile solution in sterile graduated cup
- Clamp catheter just below specimen port
- Draw sterile solution in syringe w/aseptic technique (30-50 mL)
- Place sterile cap on tip of syringe
- Attach capped, sterile needle on end of syringe
- w/circular motion clean injection port w/antiseptic swab (same port for specimen collection)
- insert tip of needleless syringe by twisting into irrigation port
- Alternative: insert needle through port at 30 degree angle toward bladder
- slowly inject fluid into catheter and bladder
- withdraw syringe, remove clamp and allow solution to drain into drainage bag
- closed continuous irrigation pg 1083
What are two modalities of renal replacement therapy?
- 1. Dialysis
- A. Peritoneal: indirect method of cleaning blood of waste products using osmosis an diffusion w/the peritoneum functioning as a semipermeable membrane. Removes excess fluid and waste products from bloodstream when a sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via surgically placed catheter.
- B. Hemodialysis: requires a machine equipped with semipermeable filtering membrane (artificial kidney) that removes accumulated waste an excess fluid from blood. In dialysis machine dialysate fluid is pumped through one ide of filter membrane (artificial kidney) while pts blood passes through other side. Process of osmosis, diffusion and ultrafiltration clean pts blood. Blood returns through specially placed vascular access device.
- 2. Organ transplantation: immunosuppressives are administered often for life to prevent organ rejection. Pt can regain normal kidney function
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