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82 Cards in this Set

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Developmental Factors for Adults:
Females
Males
Elders
Females: urgency, incontinence (inability to control void)
Male: prostatic hypertrophy (enlarged prostate) if malignant: they need surgery; if benign: can debulk to reduce the size.
elders: kidney's don't function well, excretion may be slower.
Psychosocial problems involved with urinary problems
*embarrassment of going in hospital; some people need major privacy while voiding, so we need to make sure that we provide this.

*children are embarrassed when learning control.
How many fluids do adults need each day?
1500-3000 mL

1 oz = 30 mL
8 oz= 240 mL

note: we lose fluid by voiding, sweat,and exhalation but can only measure voiding.
Can food intake affect urine?
YES!!
example: beets can color urine red; vitamins can change urine color. Also, we can't measure liquid in food but it is there.
what type of medications promote urine?
DIURETIC
How does aging affect bladder/urination?
when you age the muscle tone in the bladder decreases; pelvic muscles weaken; bladder begins to sag and may not empty properly.
What is a cystoscope?
During a cytoscopy procedure the bladder, ureter, and urethra can be looked by a cytoscope (a lighted instrument) that is inserted in the urethra.
Polyuria
A lot of urine; more than usual

example: diabetes mellitus
Anuria & Oliguria
Anuria: no production of urine
example: kidney failure

Oliguria: very little urine, scant
*less than 30 mL/hour and 500 mL/day
What are the different alterations in urinary elimination and their definitions?
1. Frequency and Nocturia: voiding during hours of sleep.
2. Urgency: must void NOW
3. Dysuria: painful, difficult urination
4. Enuresis: involuntary voiding
- Nocturnal enuresis: bedwetting; need to be sensitive to child and parent when this occurs. Will need to treat with medication or behavior counseling.
NANDA has 4 types of urinary incontinence, name them and give a definition.
1. Functional: bathroom to far away; they can't get to it and void.

2. Reflex: involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached: ex. spinal cord injury and can't control.

3. Stress: sudden leak of urine occuring with activities that increase abdomial pressure: sneeze, laugh, cough.

4. Total: continuous and unpredictable passage of urine.
urge urinary incontinence
involuntary passage of urine that occurs soon after a strong sense of urgency to void.
overflow urinary incontinence
urinary retention: overflow sitting in bladder longer than it should be. after taking out foley catheter you need to watch to make sure patient goes the bathroom on their own.
Neurogenic bladder
impaired neurologic function can interfere with the normal mechanism of urine. someone with a neurogenic bladder can't perceive bladder fullness adn they are unable to control their urinary sphincters. As a result, the bladder becomes distended or spastic with frequent urinary urination.
urinary retention
occurs when fully emptying of the bladder is impaired. as a result, the bladder becomes overdistended which is known as urinary retention.
when measuring urinary output, what are the normal measurements and dangerous measurements?
NORMAL: 60 mL/hour or 1200-1500/day

ABNORMALLY HIGH:

ABNORMALLY LOW:
Diagnostic test of urine: IVP (define)
Intravenous pyelography: die is injected intravenously and then e-rays are taken to evaluate the urinary structures.
Diagnostic test of urine: UA (define)
Urinalysis
Diagnostic test of urine: CCU (define)
Clean Catch Urine: make assessment, don't assume they can do this on their own. During this test, voided specimens are collected when a urine culture is needed to identify microorganisms causing a UTI. Care is taking to make sure specimen is as free as possible from contamination.
What is a culture and sensitivity?
Culture:

Sensitivity:
How to prevent UTI's
1. drink 8 - 8 ounce glasses of water a day.

2. void frequently (every 2-4 hours) to flush out bacteria.

3. avoid using harsh soaps, powders, sprays, or bubble baths.

4. avoid tight fitting pants or anything that does not provide proper ventilation.

5. wear cotton underwear.

6. wipe front to back (females)

7. take showers instead of baths.
How to manage urinary incontinence: Bladder Training
1. instruct the client to postpone voiding, resist or inhibit the sensation of urgency, and void according to a time table. Gradually, lengthen the intervals between urination to stabilize bladder and diminish urgency.

2. Habit Training: have the patient void according to a timed or scheduled plan. They will begin to void at regular intervals. don't discourage voiding if they do have the urge (unlike bladder training)

3. Prompted voiding: nurse encourages patient to to try to use the toilet and continue to remind them when to void.
Kegal Exercises
used with bladder training and management of urinary incontinence:

1. contract pelvic muscles (pull the vagina, rectum, urethra up inside) and hold for a 3-5 second count; relax for same amount of time and then repeat.

2. Initially, perform 10 intervals three times a day. Gradually increases to 10 second count for contraction and relaxation.
3. develop a schedule to perform these exercises.

4. to control stress incontinence: perform pelvic muscle contraction when initiating any activity that increases abdominal pressure.

**also, have female patient stop urination midstream; start and stop stream of urine.
External Catheter: definition, advantage, disadvantages
it's put on like a condom;
the advantage is that it causes much less infection since it goes on the outside of penis.
Disadvantage: doesn't stay on very well; doesn't hold great for everyone; better for people who don't move around a lot; and they come off very easily.
Self Catheter: why use, how to use, etc.
used by clients who have some form of neurologic bladder dysfuntion such as a spinal cord injury.
* allows client to remain independence and maintain control of bladder
* reduces changes of UTI
Foley Catheter
also called retention catheter. would use: to relieve discomfort bc of distention; to assess amount of residual urine if the bladder can't empty completely; to obtain sterile specimen; to empty bladder completely prior to surgery (or during); to get accurate measurement or urine output for ill clients whose output must be monitored hourly; to provide continuous bladder drainage; to manage incontinence when other methods have failed.
What can a nurse due for clients with retention catheter?
make sure they get plenty of fluid intake

dietary measures to prevent UTI's and increase chances for acidic urine include eating tomatoes, eggs, cheese, meat/poultry, whole grains, cranberries, plums.

Also, make sure perineal area is always clean; done anytime bath is given; very frequently; clean with soap and water.
which type of foods produce more alkaline urine?
milk products, legumes, meat, most fruits and veggies.
What is the best kind of catheter for patients with a long term Foley?
Silicone (it's very expensive)
Urinary Irrigation
Flushing or washing out of the bladder with a specific solution. It is done to wash out bladder or apply medication to the bladder lining. Done with catheter to remove pus or blood clots that are blocking the catheter.
Suprapubic Catheter
used to get urine out of the way if having surgery or has wounds. The catheter is inserted surgically though abdomen wall into urinary bladder. Stylette used for placement. May be sutured in place. You don't need a balloon for this method.
Urinary Diversions
Surgical rerouting of urine from the kidneys to a site other than the bladder. 2 categories: incontinent and continent.
What is incontinent urinary diversion
clients have no control over passage of urine and require the use of external ostomy appliance to contain urine. examples: ureterostmy (ureters brought to the side of abdomen to form stomas), nephrostomy (diverts urine from kidneys to stomas), vesicostomy (bladder wall is attached to an opening in the skin below the naval, forming an incontinent stoma), ideal conduit (most common; part of ileum in removed, intestional ends reattached, one end of portion is is closed to create a puch, and other end is brought out through abdomen wall to create a stoma. .
Continent Urinary Diversion
a continence mechanism is created which gives the client control over the passage of urine. this is done by an intermittent catheter of internal reservoir (kock pocket) or by strained voiding (neobladder)
What are the 5 steps in the Nursing Process?
1. Assess
2. Diagnose
3. Plan
- Goals, Outcomes
- Interventions
4. Implement
5. Evaluate
What is a systematic, rational method of planning and providing nursing care?
the Nursing Process
List 4 Goals of the Nursing Process
1. Identify the client's health status
2. Actual or potential health care problems
3. establish plans to meet the identified needs.
4. deliver specific nursing interventions to meet those needs.
The Nursing Process is cyclical...describe this.
it follows a logical sequence. At the nd of the first cycle, care may be terminated if goals are achieved. Or, the cycle may being again with reassessment. It will follow the same pattern: assess, diagnose, plan, implement, and evaluate.
What is the nursing process directed toward?
it is directed toward the CLIENT'S response to illness. We focus on the relief of pain.

the medical process focuses on the disease; they want to identify the problem.

*both systems work together.
other major things to remember about the nursing process....
* helps to individualize care
*communication is key (this way, we can make a better care plan)
* developing rapport is critical (important to develop a relationship so they know you care about them)
True or False?
The nursing process is collaborative with the patient, family, and other health care team members: TRUE

The nursing process is universally applicable (it applies to everyone at every age) TRUE

The Nursing Process requires critical thinking TRUE
Explain step 1: Assessment
- it continues through all phases of the nursing process.

- value depends on accurate and complete collection of data.
What is the major goal of the Assessment?
To identify the client's nursing care needs.
What are the 4 types of Assessment?
1. Initial: during the initial assessment you will follow agency policy. regular/normal.
2. Emergency: assessment will focus only on the emergency.ex. gun shot wound/heart attack
3. Problem-Focused: assessment focuses on the problem at hand: ex. someone is in premature labor.
4. Time Lapsed: (reassessment) assessment to follow up at the appropriate time. ex. gave pain medicine to patient good for 4 hours, you would check and make sure how they are doing.
What does a nurse need in the DATABASE?
- nursing history and physical exam
- physicians history and physical
- results of lab and diagnosis test
- info communicated by other health care personnel
Who does assessing involve?
- Active participation of client and nurse.
- Client can be individual, family, or community (include other people if necessary)
What are the different types of data you will receive?
Objective: something you can see
ex. swelling, smiling
Subjective: something the client complains of/reports.
ex. complains of pain

**you would like to have both.
What are the sources of this data?
Primary source is the client

Secondary source are the signs, other health care personnel, relevant literature, old records, charts, but always consider the age of the records.
What are the different methods of collecting data?
1. Observing
2. Interviewing
- directive (you have questions in front of you)
- nondirective(have the client talk/take direction)
3. Examining
Suggested Sequence
1. Clinical signs of client distress: pale, flushed, labored breathing, behavior indicating pain or emotional distress.
2. threats to client safety; real or anticipated
3. presence and functioning of associated equipment
4. immediate environment including the people in it.
Validation...what are the things you should avoid doing during an assessment??
*Be careful about assumption
*Avoid inaccuracies
*Avoid Incomplete date
What is the second step in the Nursing Process?
Diagnosing:
NANDA - North American Nursing Diagnosis Association. est. 1973; this is the naming system for nurses.
what is the NANDA definition of nursing diagnosis?
- a clinical judgement about individuals, family, community responses to an actual or potential health problem/life process.

- the nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
What sort of things does the nursing diagnosis describe?
ACTUAL health problems such as
-diarrhea
-constipation
-impaired skin integrity
-etc.
What would a risk nursing process, wellness nursing process, and possible nursing process describe?
risk nursing process: CVA victim with right side weakness has an increased RISK of falling.

wellness nursing process: if you are pregnant with first baby and you know absolutely nothing about taking care of an infant. the nurse would recognize this need for EDUCATION and PLANNING.

possible nursing diagnosis: you suspect something but don't have enough information on it yet. example: client with a possible eating problem.
The diagnosis follows Maslow's Hierarchy of Human Needs...what are they?
1. Physiologic needs
2. Safety and Security
3. Love and Belonging
4. Self-Esteem
5. Self Actualization
(listed in order of importance)
How do you as a nurse develop diagnostic statements?
you have to analyze and syntheszie your objective and subjective data. you will have to choose some diagnostic statements because you can't use them all.
would you pay attention to cues in the diagnostic or assessment stage?
definitely the DIAGNOSTIC stage. you want to compare the client's date against standards and norms to identify significant and relevant cues. **you are looking for cues that are different (out of the ordinary)

a cue is a piece of information that influences decisions.
What are some guidelines for identifying significant cues?
- cues that point to change in the client's health status or pattern.
- cues that vary from norms of the client's population
- cues that indicate a developmental delay.
when forming a nursing diagnosis, what are important things to remember?
- establish casual relationships between health problems and factors related to them
example: pain doesn't tell you much BUT, pain related to a surgical incision does. it tells you where to start with the nursing intervention plan.
What is the format of the nursing diagnosis?
1. The problem
2. use the diagnostic category label or title from your NANDA list.
What is the etiology for nursing diagnosis?
The etiology gives one or more probably causes of the health problem and gives direction to the required therapy.
Writing the diagnostic statement
it can be 2 part or 3 part

2 part: problem and etiology
JOIN problem, etiology with the words related to (r/t)

2 PART:
constipation related to dietary changes or constipation related to decreased physical activity and dietary changes.

3 PART:
example: constipation related to dietary changes manifested by patient complaints of "feeling of fullness" ; not being able to defecate; and absence of BM since 1/10.
Is this 3-part or 2-part?

Pain related to surgical procedure
manifested by
complaints of incisional pain and grimacing when turning in the bed.
3 PART
What is step 3 in the Nursing Process and give it's definition.
Planning:
process of designing the nursing strategies or intervention required to prevent, reduce, or eliminate client health problems identified and validated during the diagnostic phase.
What are the priorities of the planning stage?
it depends on the client's situation; it will change over time; and it's best if the client helps to establish their priorities.
List some factors related to priority setting.
- client values and beliefs
- resources available to nurse and client, including TIME
-Urgency of the problem
- medical treatment plan (taking into consideration the other plans of other medical care personnel)
What is the difference between goal and goal attainment?
Goal: to be broad and general. it is the desired outcome or change in client behavior in the direction of health.

Goal Attainment: reflects the resolution of the clients concern or health problem that is specified in the nursing diagnosis.
what is the outcome criteria in the planning process?
(these are like the objectives that you want to see happen)
- state in terms of client behaivor
- outcome means result of activity, rather than the activity itself.
-synonymous with behavioral objectives
- SPECIFIC and MEASUREABLE

Example: High risk for infection
Goal: Absence of Infection

outcome criteria: no signs/symptoms of infection (no redness, swelling, pain, no fever, no excessive drainage prior to discharge)
When planning what else do you need to consider when planning an outcome?
-must provide time span for planned activties
-there needs to be a guide for evaluation of progress
-you also need to the nurse know when the problem is resolved.
What do you need to ask yourself in order to write an outcome criteria?
How will the client look or behave if the desired goal is achieved?

What must the client do

How well must the client do it before the goal is attained?

example: Self-Care Deficit, Dressing
Goal: client will be able to dress self after CVA.
Outcome Criteria: client will be able to don shirts that buttons in front by x date.
client will be able to don elastic waist pants by x date.
client will be able to slip on shoes by x date
Should goals and outcome criteria be derived from one or many different nursing diagnoses?
ONLY ONE nursing diagnosis should be used to plan a goal and outcome criteria.
NOT: client will be able to feed and dress self by time of discharge. TOTALLY INCORRECT AND UNREASONABLE.
List the following terms as right or wrong.
"the wound will look better" WRONG

"there will be no purulent drainage from the wound by x date" RIGHT

"there will be no erythema at the would edges by x date" RIGHT
how does the nurse choose intervention?
- it must be safe and appropriate for the individual's age, health,etc.
-it needs to be achievable with the resources available.
-congruent with the client's beliefs and values
- and congruent with other therapies
What are the 5 things always included when writing a nursing intervention/nursing order?
1. date
2. action verb (observe)
3. content area (what are where of the order)
4. time element (q4h)
5. signature (accountability)
should you write an order that only you can understand or one that other health care personnel can follow?
Definitely write in a manner that others can follow. orders for:
observation,
prevention,
treatment,
health promotion
Does the RN delegate or do all the work?
DELEGATES
However, the RN retains accountability.

you must delegate appropriately

and supervise appropriately

since you name is on the line.
What does the Concept Map Care Plan focus on?
It focuses on the actions nurses must take to address the client's needs and meet stated goals.

1. it looks at the client holistically
2. it is based on the nursing process
3. standardized/computerized versions are available to use as resources.
what is involved with discharge planning?
anticipating and planning for needs after discharge from hospital or other facility.
What are things to consider while discharge planning?
-physical care needs
-availability of family and friend caregivers
-home environment
-client/family resources
-community resources
-(hospice, american cancer society, transportation)
What is step 4 in the nursing process and give a definition.
step 4: IMPLEMENTING
Definition: putting care plans into action
---carrying out nursing and physician orders
What are the 2 types of nursing actions involved with implementing?
1. Independent: nurse's own knowledge and skill.

2. Dependent: carried out on doctor's order (or nurse practitioner); it's usually directly related to client's disease; importance should not be minimized.