Nur111 Chapter ?? - Bowel Elimination - Bed Alignment - Catheters - Rest - Specimens - Vitals

Front 1

Purpose of Urinary System

Back 1

removes waste products from the blood, and maintains the body's water balance

Front 2

Normal urination rates

Back 2

Adults-produce 1500mL, or 3 pints of urine a day
Infants- produce 200-300mL of urine a day/should have 6-20 wet diapers a day

Front 3

Factors affecting urine production

Back 3

age, disease, the amount and kinds of fluid ingested, dietary salt, body temperature, perspiration, drugs

Front 4

Normal urine

Back 4

is pale yellow, straw-colored, or amber, is clear with no particles, has a faint odor

Front 5

Obervations and Reporting for urine characteristics

Back 5

observe for color, clarity, odor, amount, and particles.
Report complaints of urgency, burning,or painful/difficult urination

Front 6

Fracture pan use

Back 6

for people with casts, in traction, with limited back motion, after spinal injury/surgery, after a hip fracture, after hip replacement; orthopedic type injuries

Front 7

Commodes

Back 7

allow a normal position for elimination, and provide support and help prevent falls-are used for people unable to walk to bathroom often

Front 8

Effects of incontinence

Back 8

embarrassing, uncomfortable, skin irritation, infection, and pressure ulcers are risks, falling is a risk, person's pride, dignity, and self-esteeem are affected; good skin care and dry garments/linens are essential

Front 9

stress incontinence

Back 9

Dribbling occurs with sneezing, laughing, coughing, lifting, or other activities due to obesity, late pregnancy, common for women in menopause, pelvic muscles weaken with pregnancies and aging.

Front 10

Urge Incontinence

Back 10

urinary frequency, urgency, and night-time voidings are common. Causes include UTI, alzheimers, nervous system disorders, bladder cancer, and enlarged prostate

Front 11

Overflow incontinence

Back 11

Small amounts of urine leak from full bladder, person canot completely empty the bladder, has weak urine stream or only dribbles can be cause by diabetes, enlarged prostate, some drugs, and spinal cord injuries

Front 12

functional incontinence

Back 12

may be caused by immobility, restraints, unanswered call lights, no signal light within reach, not knowing where to find bathroom, difficulty removing clothings, confusion, and disorientation

Front 13

reflex incontinence

Back 13

the person does not feel like they need to void, so urine is lost at predictable intervals when bladder is full. Caused by nervous system disorders and injuries

Front 14

transient incontinence

Back 14

may be temporary due to delirium, uti, drugs, increased urine production, restricted mobility, and fecal impaction

Front 15

Causes of incontinence

Back 15

weakened pelvic muscles, uti, alzheimers disease, nervous system disorders, bladder cancer, enlarged prostate, diabetes, spinal cord injuries, immobility, restraints, unanswered call lights, no call light within reach, unable to find bathroom, confusion, increased urine production, restricted mobility, fecal impaction, surgeries

Front 16

Catheter use

Back 16

before, during, after surgery; for people who are too weak/disabled to use bedpan, urinal, commode, or toilet; to protect wounds and pressure ulcers from contact with urine; to alow hourly ouput measurements (strict output), as last resort for incontinence, certain diagnostics

Front 17

Catheter caution

Back 17

Indwelling catheters put patient at high risk of infection

Front 18

drainage systems

Back 18

a closed drainage system is used for indwelling catheters, nothing can enter system from the catheter to the drainage bag, the drainage bag must not touch the floor, must be kept lower than the person's bladder, some people wear leg bags when up. make sure to attach tubing to patient leg and sheets to prevent/reduce movement

Front 19

accidental disconnection of drainage system

Back 19

do not touch ends of catheter or tubing, practice hand heygiene and put on gloves, wipe end of tube with antiseptic wipe, wipe end of catheter with another antiseptic wipe, do not put ends down, connect tubing to the catheter, discard wipes into biohazard, remove gloves and perform hand hygiene

Front 20

Drainage bags are emptied and urine is measured:

Back 20

at end of every shift, when changing from leg bag to drainage bag, when changing from drainage bag to leg bag, when bag is becoming full

Front 21

removing an indwelling catheter

Back 21

has 2 lumens (passageways) one to inflate balloon with sterile water, and one to drain urine from the bladder. Must have dr orders to remove catheter. most people need bladder training first, and dysuria and frequency are common after removal

Front 22

condom catheters

Back 22

soft sheath that slides over penis. to apply follow manuf. instructions, thoroughly wash penis with soap and water, dry penis before apply catheter. some are self-adhering or applied with elastic tape

Front 23

bladder training

Back 23

helps some people with urinary incontinence, some need after indwelling catheter is removed, control of urination is the goal, assist with training as directed

Front 24

Factors affecting bowel elimination

Back 24

privacy, habits, age, diet (high-fiber foods/other foods), exercise and activity, fluids, drugs, disability, aging

Front 25

normal bowel elimination

Back 25

time and frequency vary, stools are normally brown, soft, formed, moist, and shaped like the rectum; stools have normal odor cause by bacterial action in intestines

Front 26

Catheter use

Back 26

before, during, after surgery; for people who are too weak/disabled to use bedpan, urinal, commode, or toilet; to protect wounds and pressure ulcers from contact with urine; to alow hourly ouput measurements (strict output), as last resort for incontinence, certain diagnostics

Front 27

Catheter caution

Back 27

Indwelling catheters put patient at high risk of infection

Front 28

drainage systems

Back 28

a closed drainage system is used for indwelling catheters, nothing can enter system from the catheter to the drainage bag, the drainage bag must not touch the floor, must be kept lower than the person's bladder, some people wear leg bags when up. make sure to attach tubing to patient leg and sheets to prevent/reduce movement

Front 29

accidental disconnection of drainage system

Back 29

do not touch ends of catheter or tubing, practice hand heygiene and put on gloves, wipe end of tube with antiseptic wipe, wipe end of catheter with another antiseptic wipe, do not put ends down, connect tubing to the catheter, discard wipes into biohazard, remove gloves and perform hand hygiene

Front 30

Drainage bags are emptied and urine is measured:

Back 30

at end of every shift, when changing from leg bag to drainage bag, when changing from drainage bag to leg bag, when bag is becoming full

Front 31

removing an indwelling catheter

Back 31

has 2 lumens (passageways) one to inflate balloon with sterile water, and one to drain urine from the bladder. Must have dr orders to remove catheter. most people need bladder training first, and dysuria and frequency are common after removal

Front 32

condom catheters

Back 32

soft sheath that slides over penis. to apply follow manuf. instructions, thoroughly wash penis with soap and water, dry penis before apply catheter. some are self-adhering or applied with elastic tape

Front 33

bladder training

Back 33

helps some people with urinary incontinence, some need after indwelling catheter is removed, control of urination is the goal, assist with training as directed

Front 34

Factors affecting bowel elimination

Back 34

privacy, habits, age, diet(high fiber foods/other foods), exercise and activity, fluids, disability, aging

Front 35

normal bowel elimination

Back 35

time and frequency vary, stools are normally brown, soft, formed, moist, and shaped like the rectum; stools have normal odor cause by bacterial action in intestines

Front 36

Charting Bowel elimination

Back 36

Observe and report: color, amount, consistency, presence of blood or mucus, odor, shape, frequency, complaints of pain or discomfort

Front 37

Common Elimination Problems

Back 37

constipation, fecal impaction, diarrhea, fecal incontinence, and flatulence

Front 38

Common Causes of constipation

Back 38

low-fiber diet, ignoring urge to have BM, decreased fluid intake, inactivity, drugs, aging, certain diseases, feces moves slowly through the bowel

Front 39

How to relieve or prevent constipation

Back 39

Dietary changes, fluids, activity, drugs, enemas, stool softeners, laxatives, suppositories

Front 40

Fecal Impaction

Back 40

results if constipation is not relieved, person cannot have BM, or has liquid feces seep out past the blockage. Detected by a digital exam and may be removed by gloved finger (digital removal of impaction)

Front 41

Cautions for fecal impactions

Back 41

checking and removing can be dangerous as vagus nerve can be stimulated causeing the heart rate to slow to dangerous levels

Front 42

Causes of diarrhea

Back 42

infections, some drugs, irritating foods, microbes in food/water. feces moves rapidly through intestines which reduces fluid absorbtion, abdominal cramping, nausea, and vomitting may occur.

Front 43

Caring for diarrhea

Back 43

diet and drugs may be ordered to reduce peristalsis. you must assist with elimination needs, dispose of stools promptlly, give good skin care, provide fluids to reduce risk of dehydration, follow standard precautions and bloodborne pathogen standard

Front 44

Causes of fecal incontinence

Back 44

intestinal diseases, nervous system disease and injury, fecal impaction, diarrhea, some drugs, chronic illness, aging, mental health problems or dementia, not answering signal lights, not getting to bathroom in time, not finding bathroom in new setting

Front 45

Fecal Incontinence-Persons needs

Back 45

may need bowel training, help with elimination after meals and every 2-3 hours, incontinence products to keep garments/linens clean, good skin care

Front 46

Causes of flatulence

Back 46

swallowing air while eating and drinking, bacterial reaction in the intestines, gas forming foods (onions, beans, cabbage, cauliflower, radishes, cucumbers), constipation, bowel/abdominal surgeries, drugs that decrease peristalsis

Front 47

Problems from flatulence

Back 47

if flatus is not expelled intestines distend, swelling and enlarging from pressure, abdominal cramping/pain, shortness of breath, and swollen abdomen occur

Front 48

Relieving flatulence

Back 48

exercise, walking, moving in bed, left side-lying position. doctors may order enemas or drugs to relieve

Front 49

bowel training

Back 49

Goals are to gain control of bowel movements, and develop a regular pattern of elimination. factors promoting elimination are part of plan

Front 50

When are enemas used?

Back 50

doctors order them to remove feces, to relieve constipation, fecal impaction, or flatulence, to clean the bowel of feces before certain surgeries and diagnostic procedures

Front 51

Enema solutions

Back 51

are ordered by doctor and can be tap water, saline, soap suds, small-volume, oil retention, other solutions

Front 52

Tap water enema

Back 52

is obtained from a faucet. only 1 tap water enema is given as colon may absorb water into bloodstream, repeated enemas increase risk of fluid absorbtion/imbalance

Front 53

saline enema

Back 53

a solution of salt/water. for adults add 1-2 tsp salt to 500-1000mL of water. Must still be careful as body may absorb salt solution creating fluid imbalance

Front 54

Soapsuds enema

Back 54

is for adults only. add 3-5 mL of castile soap to 500-1000 ML of water. can irritate bowel's mucus lining, can damage bowel

Front 55

small volume enema

Back 55

adult contains 120 mL solution/child contains 60 mL fluid, these are commercially prepared. tube inserted 2 inches into adults rectum

Front 56

oil-retention enema

Back 56

has mineral, olice, or cottonseed oil. adult 120mL/child 60mL; holds in rectum about 30-60minutes or until urge to have BM; softens feces and lubricates rectum, can help relieve constipation and fecal impactions

Front 57

Cleansing enemas

Back 57

used to clean bowel of feces and flatus, relieve constipation and fecal impaction, are needed before certain surgeries and diagnostic tests. may be tap water, saline, or soapsuds enema. may take 10-20 minutes to be effective

Front 58

giving an enema

Back 58

person should be in sims position, enema bag should be held 12-18 inches above rectum, reduce flow to help promote comfort, lubricate tube, insert tube 2-4 inches into rectum, take time during administration to reduce pain and discomfort

Front 59

small volume enemas

Back 59

irritate and distend the rectum and may be ordered for constipation or when bowel does not need complete cleansing.

Front 60

Person with ostomy

Back 60

opening is a stoma, and person wears a pouch over teh stoma to collect stools and flatus

Front 61

Colostomy

Back 61

if permanent the diseased part of the colon is removed. if temporary the colostomy give diseased/injured bowel time to heal, then can be reconnected. colostomy site depends on area of injury/disease

Front 62

ileostomy

Back 62

usually permanent, and liquid stools drain constantly

Front 63

Ostomy Pouches

Back 63

Stoma is not painful for patient, and skin care is very important. the pouch attaches with adhesive backing which is applied to skin, sometimes pouches are secured with belts, many have drains at the bottm that close with a clip, clamp or wire and is opened to empty pouch, pouch is emptied when stools are present, changed ever 3-7 days or when it leaks

Front 64

Vital Signs

Back 64

Include temperature, pulse,, respirations, bloodpressure, pain. reflect the functioning of 3 body processess essential for life-regulation of body temperature, breathing, and heart function

Front 65

Vital signs/measuring and reporting

Back 65

are measure do detect changes in normal body function, tell about responses to treatment, often signal life-threatening events, are part of the nursing assessment (1st step in nursing process)

Front 66

Vital signs are taken

Back 66

during physical exams, when admitted, as required by pt. condition, before/after surgery, before/after complex procedures and tests, after some care measures, after a fall or other injury, when drugs affect respiratory/circulatory system, when complaints of diszziness, light-headedness, feeling faint, shortness of breath, rapid heart rate, not feeling well, on scheduled, more frequently in ICU

Front 67

Report VS

Back 67

any VS that is changed from prior measurement, above normal range, below normal range

Front 68

Importance with vital signs

Back 68

accuracy is essential, even minor in condition can be seen, should take with person lying or sitting, arms, legs should not be crossed, arms should be lower than heart

Front 69

Temperature sites

Back 69

mouth, rectum, axilla(underarm), tympanic membrane, temporal artery

Front 70

Normal oral temp range

Back 70

97.6-99.6 F, 36.5-37.5 C

Front 71

normal rectal temp range

Back 71

98.6-100.6 F, 37-38.1 C

Front 72

normal axillary temp range

Back 72

96.6-98.6 F, 35.9-37 C

Front 73

normal tympanic membrane temp range

Back 73

98.6

Front 74

Do not take an oral temperature for:

Back 74

children under 4 or 5, unconscious, has had surgery or injury to face, neck, nose, or mouth, is receiving oxygen, breaths through the mouth, has naso-gastric tube, is delirious, restell, confused, or disoriented, is parlyzed on one side of the body, has a sore mouth, has a convulsive disorder

Front 75

do not take rectal temp:

Back 75

if person has diarrhea, rectal disorder/injury, has heart disease, is confused or agitated

Front 76

pulse sites

Back 76

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal), radial is used most often, carotid used for CPR, apical is felt over the heart

Front 77

apical pulse

Back 77

a stethescope is used to listen to apical pulse; counted for 1 full minute, count each lub-dub.

Front 78

pulse rate

Back 78

varies for each age group 0-1: 80-190, 2 yrs. 80-160, 6 yrs. 75-120, 10 yrs. 70-110, 12 and up 60-100 beats per minute

Front 79

Pulse rhythm

Back 79

reported as regular/irregular. should be regular, and irregular pulse occurs when the beats are not evenly spaced or beats are skipped.

Front 80

Pulse Strength

Back 80

is the amount of force. described as strong, full, or bounding. hard to feel pulse are described as weak thready, or feeble

Front 81

apical pulses are taken on:

Back 81

infants and children up to 2 years old, people with heart disease, persons with irregular heart rhythms, persons who take drugs that affect the heart

Front 82

Respirations

Back 82

each respiration involves one inhalation and one exhalation, should have 12-20 respirations per minute for adult, should be quiet, effortless and regular

Front 83

Control of blood pressure

Back 83

force of heart contractions, amount of blood pumped with each heartbeat, how easily the blood flows through the blood vessels. heart pumps blood during systole, rests during diastole

Front 84

Normal blood pressure range

Back 84

for an adult 90-120 mm Hg-systolic
60-80 mm Hg diastolic

Front 85

Reporting blood pressure

Back 85

report any systolic over 120 mm Hg, or below 90 mm Hg
report any diastolic over 80 mm Hg, or below 60 mm Hg

Front 86

Factors affecting blood pressure

Back 86

age, gender, blood volume, stress, pain, exercise, weight, race, diet, drugs, position, smoking, alcohol

Front 87

Reasons bedrest is ordered:

Back 87

reduce physical activity, reduce pain, encourage rest, regain strength, promote healing

Front 88

Strict bedrest

Back 88

everything is done for the person. no activities of daily living are allowed

Front 89

bedrest

Back 89

some ADL are allowed. Self-feeding, oral hygiene, bathing, shaving, and hair care are often allowed

Front 90

bedrest with commode privileges

Back 90

the person uses the commode for elimination

Front 91

bedrest with bathroom privileges

Back 91

the person uses the bathroom for elimination

Front 92

Complications from bed rest

Back 92

pressure ulcers, constipation and fecal impaction, UTI and renal calculi (kidney stones), blood clots, pneumonia, contractures, muscle atrophy, orthostatic hypotension (postural hypotension) syncope (fainting)

Front 93

Contracture

Back 93

the contracted muscle is fixed into position, is deformed, and cannot stretch. common sites fingers, wrists, elbows, neck and spine

Front 94

Preventing complications from bedrest

Back 94

may to encourage/assist person to have good alignment, range-of-motion exercises, frequent position changes

Front 95

Supportive devises for positioning

Back 95

bed boards, foot boards, trochanter rolls, hip abduction wedges, hand rolls/hand grips, splints, bed cradles

Front 96

bed boards

Back 96

are placed under mattress to prevent mattress from sagging

Front 97

foot boards

Back 97

are placed at the foot of the mattress and prevent plantar flexion and foot drop. feet are placed in good alightment as when standing. can also act as bed cradles protecting feet from top linens

Front 98

trochanter rolls

Back 98

prevent hips and legs from external rotation

Front 99

hip abduction wedges

Back 99

placed between persons legs to keep hips abducted (common after hip replacement)

Front 100

handrolls/hand grips

Back 100

prevent contractures of teh thumb fingers and wrist. foam rubber sponges, rubber balls, finger cushions

Front 101

splints

Back 101

usuall secured in place with velcro, keep elbows, wrists, thumbs, fingers, ankles, and knees in normal position

Front 102

bed cradles

Back 102

keep weight of top linen off feet and toes to prevent footdrop and pressure ulcers

Front 103

Exercise

Back 103

helps to prevent contractures, muscle atrophy, and other complications. some occur with ADL others should be done through ROM exercises

Front 104

Range of Motion exercises

Back 104

done more often for those on bedrest, who cannot walk, turn, or transfer themselves. include moving joints through their complete range of motion at least 2 times per day

Front 105

recreational activities

Back 105

OBRA requires activity programs for adults; they are important for a person's physical and mental well-being, exercise joints and muscles, stimulate circulation, are social events, are mentally stimulating, improve a persons quality of life

Front 106

Collecting/testing specimens

Back 106

to prevent, detect, and treat disease. doctors order what specimen to collect and the test needed. most are sent to the laboratory, some are done at bedside

Front 107

radome urine specimen

Back 107

can be collected at any time during a 24 hour period, for a routine urinalysis

Front 108

midstream specimen (clean-voided/clean catch)

Back 108

perineal area is cleaned before collecting specimen, person starts to void, stops stream of urine, sterile specimen container is positioned, person voids into container until specimen is contained

Front 109

24 hours urine specimen

Back 109

all urine for 24 hours is collected, urine is chilled/refrigerated during collection process, sometimes a preservative is added, person voids at the beginning to start test with empty bladder, and then save all voidings for next 24 hours

Front 110

Restarting 24 hours specimen

Back 110

occurs if voiding was not saved, toilet tissue was discarded into specimen, specimen contains feces

Front 111

double voided specimen/fresh-fractional

Back 111

person voids twice, first time bladder is emptied of stale urine then in 30 minutes person voids again and it is collected. used to test for glucose and ketones

Front 112

infant/child collection

Back 112

for non-toilet trained children use a collection bag appllied over the urethra

Front 113

testing for ph

Back 113

measures to see if urine is acidic or alkaline. a routine sample is collected

Front 114

testing for glucose/ketones

Back 114

double-voided specimens are best for this test. Diabetics make have sugar (glucose) in urine, may also have acetone in urine, urine tested for glucose and ketones, dr. uses tests to make drug and diet decisions

Front 115

testing urine for blood

Back 115

a routine urine specimen is needed, sometimes blood can be seen or unseen (occult), injury and disease can cause hematuria

Front 116

using reagent strips

Back 116

do not touch test area, dip strip into urine, compare strip to color chart on bottle

Front 117

Kidney stones (calculi)

Back 117

develops in the kidney, ureter or bladder, vary in size, can cause severe pain and urinary system damage and may require surgical removal, some are passed through urine. urine is strained and passed stones are sent to laboratory

Front 118

stool specimens

Back 118

checked for blood, fat, microbes, worms, and other abnormal content. specimens cannot be contaminated with urine, and some require warm stool

Front 119

testing stools for blood

Back 119

is seen if bleeding from lower bowels, if bleeding is in stomach or upper GI tract stools are black and tarry, sometimes cannot be seen (occult), when using kits follow manuf. instructions

Front 120

blood glucose testing

Back 120

blood glucose is tested for people with diabetes, and results help to regulate by changing pt drugs and diet. capillary blood is obtained through the skin puncture usually on a fingertip or an earlobe

Front 121

finger stick blood specimen

Back 121

inspect site carefuly for trauma, skin breaks, swelling, bruising, cyanotic, scarred, or calloused do not use. do not use middle of fleshy part of finger, but use side of fingertip with lancet, a glucose meter will measure blood glucose