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126 Cards in this Set
- Front
- Back
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Describe blood flow through the heart |
*Blood enters heart at right atrium from the body *Goes from right atrium to right ventricle *Right ventricle to pulmonary artery to lungs *From lungs to pulmonary vein to left atrium *Left atrium to left ventricle *Left ventricle to aorta *Aorta to body |
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What are some factors that affect cardiac function? |
*Age - thickening of valves and ventricular wall, decreased output *Race - AA higher incidence of HTN and heart dz *Gender - Men at increased risk until menopause and then gender neutral *Weight - Obesity is linked to heart dz *Heredity - increased risk with family history of heart dz *Lifestyle and habits - smoking, lack of exercise, diet *Coping and stress - Increased BP and HR lead to heart complications |
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What happens to the heart when a person initially lays down in supine position? |
Increase in central circulation Increase in stroke volume Increase in cardiac output may slightly decrease HR |
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What happens to the heart after prolonged bed rest/immobility? |
*Decreased venous return to heart *Compromised cardiac filling *Increased HR w/ decreased stroke volume/CO *Time in diastole is decreased b/c increased HR, so heart dose not have time to fill with blood and works 30% harder to perfuse organs and tissues |
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What are some effects of immobility on the cardiac system? |
Cardiac strain - valsalva maneuver Shift of plasma to interstitial spaces *edema *Hypovolemia *Blood hypercoaguability Orthostatic Hypotension |
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What are some warning signs of imminent CV problems? |
*Change in color of lips, face, or nails *Chest pain *Extreme diaphoresis *Dizziness *Dyspnea *Edema *Syncope *Extremity pain *Fatigue *Feeling of doom *Pain limiting self care *Numbness/tingling in extremities *Palpatations *Change in LOC |
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What are the grades for pulses? |
0=absent 1+=weak 2+=normal 3+=increased 4+=bounding |
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What are some characteristics of arterial insufficiencies? |
*Extremities are cold to touch *Dependent rubor - dusky red when legs down *Palor on elevation of legs *Thin, shiny skin *Thickened nails *Decreased hair growth *Decreased or absent pulses *Absence of peripheral edema |
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What are some characteristics of venous insufficiencies? |
*Color of legs are normal or brownish discoloration on ankles and feet *Pulses are normal *Peripheral edema *Ulcers on legs *Varicosities *normal temp of extremities |
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Edema in lower extremities can be a sign of HF in which side of heart? |
Right |
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What can it mean when a patient gains 2 or more pounds in a 24 hour period? |
Fluid retention |
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How many liters of fluid is retained for every 1 kg of weight gained? |
1 liter per 1kg |
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What are some common nursing diagnoses related to the heart? |
*Ineffective Tissue Perfusion (specify): *Decreased cardiac output *Activity intolerance |
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Describe the nursing diagnosis *Ineffective Tissue Perfusion |
*O2 is not getting to where it needs to go, circulatory issue (GI, renal, Cardiopulmonary, cerebral, peripheral) *s/s - Cardiopulmonary - Dyspnea, altered blood gasses, chest pain, SOB Peripheral - color changes in extremities, loss of pulses, temp changes, pain in extremities, peripheral edema Cerebral - confusion, dizziness, LOC changes |
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Describe the nursing diagnosis * Decreased CO |
Inadequate blood volume by heart to meet metabolic demand of body. S/S - Fatigue, SOB, altered heart rate, Jug vein distention. |
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What are the nursing goals and interventions for Ineffective Tissue Perfusion? |
Goal - Prevention of permanent tissue damage via improvement of circulation Interventions - *Modify risk factors *Prevent vasoconstriction (meds, warmth) *Admin medications *Prevent post-op complications |
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What are the nursing goals and interventions for Decreased Cardiac Output? |
Goal - Reduce cardiac workload/decrease oxygen demands Interventions - *Promote rest *Positioning *Avoid valsalva maneuver *Avoid stimulants *maintain fluid balance *Med mgmt *Increase O2 supply |
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What are some common Lab and Diagnostic tests for Cardiac issues? Part I |
*Cardiac enzymes - For MI, Troponin etc. *CBC - H&H for circulating blood volume *Coag studies - PT coumadin/PTT heparin *Lipid profiles (cholesterol studies) - HDL, LDL, and triglycerides *Electrolytes - especially K+ *BNP - when elevated suggest CHF *C-reactive protein (CRP) - inflammation *D-dimer - DVT |
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What are some common Lab and Diagnostic tests for Cardiac issues? Part II |
*ECG *Exercise stress testing *Doppler studies - DVTs and pulses *Echocardiogram - 3D US of heart *Cardiac cath - check for blockage, put in stent, see if needs sx *Holter monitor - Dysrhythmias *Chest rads - CHF |
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How is medicine retrieved from a glass ampule. |
Use an ampule breaker or gauze to break glass top off. Use a filter needle to get medication out while filtering out shards of glass. Change filter needle off of syringe before giving inj. |
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How should unused medication be disposed of? |
Waste it in the sink. |
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How is medication extracted from a glass vial? |
*Scrub the hub for 15-30sec with alcohol wipe *Pressurize the vial by injecting the amount of air equal to the amount of medicine you need into the vial *Invert vial, keeping needle in solution, draw up amount of medication needed. *Upright vial, carefully remove needle from vial and recap needle with one handed scoop tech. |
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What is the proper way to mix two insulin meds into one syringe? |
We mix 'dirty' (NPH) and clean. Remember to roll insulin in your hand, not shake, to warm up. 1- Air into "dirty" 2- Air into "Clean" 3- Withdraw clean 4- Withdraw Dirty 5- Inject |
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What types of syringes are typically used for injections? |
1mL to 5mL |
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How are insulin syringes different? |
They measure in units/mL *U100 on an insulin syringe is 100 units of insulin per 1mL |
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Selecting the appropriate needle for injection |
Inj Type Diameter Length Angle Intradermal 25-27g 3/8-5/8in 5-15D Subcutaneous 25-30g 3/8-5/8in 45-90D Intramuscular 18-25g 5/8-11/2in 90D |
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What are acceptable sites for IM injections? |
Deltoid Vastus lateralis Ventrogluteal |
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What is the Z track method and what is it used for? |
An IM Injection process that prevents tissue irritation caused when medication leaks into subcut layers. Displace skin and the subcut tissues at the site about 1-11/2 inches with the side of your non dominant hand. Maintain displacement throughout the injection and release it immediately after you withdraw the needle from the skin. |
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How are IM injections given? |
*At 90 deg angle with a quick darting motion. *Always aspirate the plunger to check for blood return before injecting the medication. Lack of blood indicates correct needle placement in the muscle rather than a blood vessel *Inject medication slowly and wait 10 sec to allow med to disperse. *Remove needle quickly and cover inj site with dry gauze while applying gentle pressure. DO NOT MASSAGE SITE |
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What are the landmarks for the Deltoid IM injection? |
The acromion process and the axillary line. Inject two - three finger widths below acromion, above the axillary line, in the middle of the triangular shaped muscle in the midline of the lateral aspect of the arm. |
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What are the landmarks for the Vastus lateralis MI inj? |
Inject in the middle third of the muscle at least one hand width below the greater trochanter and one hand width above the knee in the anterolateral aspect of the leg. |
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What are the landmarks for the ventrogluteal MI injection? |
Place heel or palm of hand on the head of the greater trochanter with you thumb pointing toward the patient's abdomen. Extend your index finger up to the anterior iliac spine then spread your other fingers back along the iliac crest. Insert needle in the V formed between your index and third fingers. |
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Do we give injections in the dorsogluteal site? |
No, because had too high of risk for sciatic nerve damage. |
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How is the max volume of injection, gauge, and length of needle determined? |
*Site used *Age and size of patient *Medication to be administered |
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What are the injection norms for the deltoid muscle? |
For the deltoid of an average sized adult or adolescent, give up to 1mL of med with 5/8-1in needle. DO NOT use deltoid site for infants and toddlers younger than 3yrs. For preschoolers and older children use a 5/8in needle in the deltoid. |
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What are the injection norms for the vastus lateralis muscle? |
Average adult or adolescent, give up to 3mL of med with an 18-25g, 1-11/2in needle for oil based or viscous solutions. Or 22-27g, 1-11/2in needle for aqueous solutions Infants give up to 1mL with a 1in needle. Small infants give up to 0.5mL with a 5/8in needle *preferred site for infants* |
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What are the injection norms for the ventrogluteal muscle? |
Average adult, give up to 3mL of med with an 18-25g, 1-11/2in needle for oil based or viscous solutions. Or 22-27g, 1-11/2in needle for aqueous solutions Infants give up to 1mL with a 21-25g, 1/2 - 1in needle. Small infants give up to 0.5mL with a 21-25g, 5/8in needle Toddlers give up to 2mL with a 21-25g, 1in needle. Children age 3 and older 2 to 3mL with a 21-25g, 1in needle Adolescents, give up to 3mL with a 21-25g, 1-1/12inneedle *Preferred location for administering irritating or oily solutions to patients of any age. |
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What are acceptable sites for intradermal injections? How is it administered? |
Inner forearm and upper back *Use a tuberculin or other small syringe (1mL or smaller) with a 3/8-5/8inch, 25-27g needle. Pull patient's skin taught, insert needle at a 5-15 deg angle, with bevel facing up. Insert need about 1/8 of inch. Give slowly while watching for blanching and the appearance of a wheal. Bleeding or no wheel at site means it was done improperly. |
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How are subcut injections given? |
Upper, outer aspect of the arm, 2inches from umbilicus on abdomen, or anterior thighs. Admin up to 1mL with a 25-30g, 3/8-5/8in needle. Needle length should be about 1/2 the length of the skin fold pinched. Pinch skin fold with non dominant hand and dart injection at 90 - 45deg angle for average sized person, 90 deg for obese person, and in the stomach for a thin patient. No aspiration is needed before injection of medication. Release pinch before injecting medication. |
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What organ divides the upper and lower airways? |
Glottis |
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What is ventilation and how is it done? |
Movement of air into and out of lungs (inspiration and expiration) *Controlled by both automatic and voluntary controls *Gases flow from areas of greater pressure to areas of lower pressure |
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What are some factors that influence ventilation? |
*Muscles of respiration - Diaphragm (primary) intercostals and sternoclidomastoid (accessory - abnormal situations) *Compliance - allows lungs to stretch *Elasticity - returns lungs to unstretched state *Surfactant - reduces surface tension and holds alveoli open *Airway resistance - any foreign body *Dead space - ~ 150mL of air gets lost in bronchi and does not reach the alveoli |
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What is perfusion? |
Getting oxygenated blood to the rest of the body *Accomplished via the action of the heart and circulatory system *Oxygenated blood is moved from lungs via the vascular system to the tissues and organs and then returns, deoxygenated, to the cardiopulmonary system. |
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What is needed for gas exchange to happen in lungs? |
Airflow and blood flow (ventilation and perfusion) to equally match. |
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What are some developmental considerations affecting oxygenation? |
*Premature infants - have no surfactant *Infants & toddlers - Increased risk of upper resp infections *School age - Inc risk for upper resp infections *Young and middle age adults - smoking, stress, lack of exercise *Older adults - Changes in lungs with aging, resp muscles weaken, decreased # of cilia |
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What lifestyle and environmental factors affect oxygenation? |
*Nutrition *Exercise *Smoking *Substance abuse *Stress/anxiety *Pollutants *Occupation |
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What are some physiological processes affecting oxygenation? |
*Anemia - less blood to carry O2 *Toxic inhalant - decreased O2 carrying capacity *Airway obstruction - limit O2 to alveoli *High altitude - Lower O2 in air *hypovolemia - decreased fluid volume makes blood viscus and slow moving *Increased metabolic rates - seen with fever, increase in tissue's O2 demand |
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Conditions affecting chest wall movement that affect oxygenation. |
*Pregnancy - pushes ab content onto diaphragm *Obesity - same as preg *MS abnormalities - Kyphosis, traumas, lordosis, scoliosis *Trauma - Fx ribs, incisions *NM dz - muscular distrophy *CNS alterations - Brain, spinal cord injuries *Chronic dz - COPD |
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What are the three primary alterations in respiratory function? |
*Hyperventilation *Hypoventilation *Hypoxia |
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What is hyperventilation? |
*State of ventilation in excess of that required to eliminate the normal venous CO2 |
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What is hypoventilation? |
Occurs when alveolar vent is inadequate to meet the body's O2 demand of to eliminate sufficient CO2
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What is hypoxia? |
Inadequate tissue oxygenation at the cellular level. Results from a deficiency in O2 delivery or O2 utilization at the cellular level |
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What are some causes of hypoxia? |
*Decreased hemoglobin level *Diminished concentration of O2 *Inability of tissues to extract O2 *Pneumonia *Poor tissue perfusion (shock) *Impaired ventilation (Fx ribs) |
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What is an early sign of hypoxia? |
*Confusion
*restlessness *Anxiety *Elevated BP *Increased HR *Increased RR *Dyspnea |
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What are some late signs of hypoxia? |
*Decreased LOC *Decreased activity level *Hypotension *Bradycardia *Metabolic acidosis *Cyanosis |
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What are some chronic signs of hypoxia? |
*Clubbing of fingers and toes *Peripheral edema *Right sided heart failure *Respiratory acidosis *O2 saturation <87% |
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What should we look for when assessing a patient's cough? |
*Onset: gradual or sudden *Description *Pain with cough? *Productive vs non-productive |
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What should we look for when assessing the sputum of a patient? |
Color *Clear or white mucous *Yellow or green *Rust colored *Pink, frothy Quality/consistency *Watery, stringy, frothy *Foul-smelling Quantity *Teaspoon? Tablespoon? |
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What should we look for when assessing a patient with dyspnea? |
*How much activity causes SOB?
*Onset - gradual or sudden *Dyspnea at rest? *Orthopnea or PND (paroxysmal nocturnal dyspnea) |
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What are some nursing diagnoses related to impaired oxygenation? |
*Ineffective breathing pattern *Impaired gas exchange *Ineffective airway clearance |
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What is and outcome and interventions for the diagnosis of Ineffective breathing pattern? |
Outcome - Patient will no longer use accessory muscles, no SOB Interventions - Assess: pulse ox, RR, HR, BP, coughing, edema, SOB, lung sounds Do: Elevate head of bed, O2, Resp meds, small meals, no overexertion Teach: Coughing, deep breathing, incentive spirometry, use of inhalers, stop smoking, pursed lip breathing |
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What are some nursing interventions for general impaired oxygenation issues? |
*Promote optimal functioning by - healthy lifestyle, vaccinations, pollution free environments, reduced anxiety, good nutrition. *Promote comfort by - positioning, adequate fluid intake, provide humidified air *Promote proper breathing by - Deep breathing, incentive spirometry, pursed lip breathing, diaphragmatic breathing *Promoting and controlling cough - Voluntary coughing, involuntary coughing, cough meds *Perform chest physiotherapy - Percussion, vibration, postural drainage, suctioning, O2 therapy |
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What is pulse ox and what is it used for? |
*Non invasive measurement of O2 saturation in arterial blood *Normal range is 95-100%. Less than 85% means there's not enough O2 getting to the tissues *Usually measured along with HgB levels *Measure on fingers (no nail polish), bridge of nose, earlobe, toes *Can be single test or continuous |
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Describe pulmonary function tests. |
Assess for dysfunction, dz, or dz progression
*Preformed by Dr. and respiratory therapists *Can't eat heavy meal 4-6 hours prior *No bronchodilators 4 hours prior *Void and no restrictive clothing *Mouth piece attached to computer for recording results *Nose clip to restrict nose breathing *Breathing maneuvers - inspiration, expiration, normal, forced, breath holding |
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What is the Peak Expiratory Flow Rate? |
*Volume of air that can be forcefully exhaled *Patient sitting or standing *Values recorded - Best of three rating *Normal based on height, age, and gender *Keep as comparison for future tests, after med regimen, etc. *Can be part of PFT |
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What is a thoracentesis? |
*Aspiration of fluid from pleural cavity *Done at bedside in tripod position *Fluid had to be removed to ease breathing *Sterile procedure, standard precautions, insert needle with cath then remove needle *Careful not to puncture lung *Watch for bleeding and altered breathing patterns after done. |
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What are ABGs? |
Arterial Blood Gases - blood test *Measures oxygenation and perfusion of blood *pH (7.35-7.45), PCO2 (35-45), PO2 (80-100mmHg), HCO3 (22-26) *Radial, brachial, & femoral arteries are used *Do Allen test for blood flow first *Put pressure on site for 3-5min post blood draw |
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How is a sputum sample collected for cytology? |
*Collect before breakfast for 3 consecutive days *Patient take a deep breath and expel air with a deep cough *Expectorate into a sterile container. *To look for malignancies, infections, etc. |
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What is a bronchoscopy? |
*Lighted scope put in airway to look for lesions, ulcers, and to biopsy *Examines larynx, trachea, and bronchi *NPO for 4-8 hours prior to test *Local anesthetic is used *No food after procedure until gag reflex returns *Monitor respiratory function *Saline gargles for throat irritation |
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What is a lung scan (ventilation/perfusion scan or V/Q scan)? |
A dye is injected into the patients vein and then the lungs are scanned to watch the circulation. This will determine if the issue is with V or Q. *No special care is needed after this test. |
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What % of O2 is room air? |
21% |
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How is O2 therapy given? |
*Nasal cannula *Simple mask *Partial - rebreathing mask *Non-rebreathing mask *Venturi mask O2 is very drying so if patient is getting more than 2L/min than it should be humidified. |
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Describe O2 therapy with a nasal cannula? |
1-6L/min *Watch for skin break down along face and behind ears |
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Describe O2 therapy with a simple mask |
*FIO2 35% - 60% *Connected to flow meter and humidifier *Has vents to let CO2 out and some room air in *Min of 5L/min |
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What is FIO2? |
Fraction Inspired Oxygen 1L = 24% 5L = 35% 6L = 44% |
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Describe O2 therapy with a partial rebreather. |
*Mask with reservoir bag *FIO2 70-90% *Bag collects first part of patient's exhaled air while other part leaves through vents *Patient breaths a combo of 100% O2 and some of their own expired air *Hard to eat, talk, and keep in place |
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Describe O2 therapy with a non rebreather mask. |
*Highest concentration of O2 delivery via mask *FIO2 = 60-100% *2 way valves prevent rebreathing of exhaled air *Reservoir is filled with O2 that enters mask on inhalation *exhaled air leaves through side vents |
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Describe O2 therapy with a venturi mask |
*Most precise O2 concentration *Tube with O2 inlet *As tube narrows the pressure drops causing air to come in from side ports *Ports are always open but are adjusted according to prescribed amount of O2 |
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Where does the GI tract begin and end? |
Mouth to anus |
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Describe the large intestine |
*~5ft long *Primary organ of bowel elimination *Extends from iliocecal valve to anus *Functions - completion of absorption, manufacture of some vitamins, formation of feces, and expulsion of feces from body *Ileocecal valve connects sm intestine w/ lg. *Cecum is the 1st part of the large intestine, ascending colon, transverse colon, descending colon, sigmoid colon |
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Describe the rectum |
*Empty until need to defecate
*Folds in rectum with arteries and veins (this is the vein that can become a hemorrhoid) |
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Describe the process of peristalsis |
*Under control of the nervous system (parasymp stimulates, symp inhibits) *Contractions occur every 3-12 min *Mass peristalsis sweeps occur 1-4 times every 24 hours *1/3-1/2 of food waste is excreted in stool q 24h *If it is too fast diarrhea occurs *If it is too slow constipation occurs |
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What are some variables influencing bowel elimination? |
*Developmental considerations *Daily patterns - timing convenience *Food and fluid *Activity & muscle tone - helps w/ constipation *Lifestyle, psychological - *pathologic conditions - crone's IBD *Medications *Diagnostic studies *Sx and anesthesia - slows bowels |
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What is a lifestyle, psychological variable influencing bowel elimination? |
*women have more probs with constipation than men because not lady-like to poop in public so women hold it *Psych stress increases parastalsis |
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What are some developmental variables influencing bowel elimination? |
*Infants - characteristics of stool depend on breast milk or formula and frequency *Toddlers - psych maturity is first priority for bowel training *Child, adolescent, adult - defecation patterns vary in quantity, frequency, and rhythmicity *Older adult - constipation is often a chronic problem |
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Name and describe foods that affect bowel elimination. |
*Constipating foods - Cheese, lean meat, eggs, pasta *Laxative effect foods - fruits, veggies, bran, chocolate, alcohol, coffee *Gas producing - onions, cabbage, beans, cauliflower |
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Describe some effects medications have on stool |
*Aspirin, anticoags - pink to red to black stool *Iron salts - black stool *Antacids - white discoloration or speckling in stool *Antibiotics - green-gray color due to impaired digestion (prone to causing diarrhea) |
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Describe stool collection |
*Medical aseptic tech is imperative *Wear gloves *Wash hands before and after *Do not contaminate outside of container with stool *Obtain stool and package, label, and transport according to agency policy |
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What goes on the stool sample label? |
Patients name, date, time, nurse's initials, what specimen is to be tested for. |
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What are the patient guidelines for stool collection? |
*Void first so stool is not contaminated by urine *Defecate into the container rather that toilet *Do not place toilet paper in container *need 1inch of formed stool or 15-30mL of liquid stool. |
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What are some direct visualization studies of the GI system? |
*EGD *Colonoscopy *Sigmoidoscopy *Wireless capsule endoscopy - takes pic q 2 seconds. patient returns after 8 hours to down load info. Will pass in 24-48 hours. |
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Describe patient education and nursing interventions for an EGD |
*NPO 24 hours prior
*Remove dentures *Patient sedated but awake *Numbing agent on throat *Post procedure nurse check gag reflex, vitals,soar throat education (salt water gargle, lozenges), look for perforation (bloody stool, vomiting blood, difficulty swallowing) |
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Describe patient education and nursing interventions for a colonoscopy. |
*Clear liquid diet and bowel prep (laxatives, suppositories, enemas, fluid to drink, golytle) *Patient sedated *Post care - bowel sounds, some pain, gas pain, gas in general b/c inflated color for better visualization, resume normal diet after sedation *Check for perforation - ab distention, pain, rectal bleed, fever |
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Describe patient education and nursing interventions for a sigmoidoscopy |
*Light meal *2 enemas *no sedation *Post op - gas pain from air added, watch for perforation |
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Describe patient education and nursing interventions for wireless capsule. |
*NPO 10-12 hours before and 1-2 hours after swallowing capsule *Start with liquids after swallow *4hrs after small meal *Cannot biopsy |
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How can nurses promote regular bowel habits? |
*Timing - when does pt go every day *Positioning - raise head of bed with bed pan *Privacy *Nutrition - fluids, fruits, fiber *Exercise - any kind |
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What individuals are at high risk for constipation? |
*Patients on bed rest taking constipating meds (opioids) *Pts with reduced fluids or bulk in diet *Pts with depression (not eating properly, sedentary) *Pts with CNS disease or local lesions that cause pain |
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Methods of emptying the colon of feces |
*Enemas *Rectal suppositories *Rectal catheters *Digital removal of stool - for impactions |
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What are the types of enemas? |
*Cleansing - soap, warm tap water (for tests or to help bowel function return) *Retention - oil, medicated (stay in bowel for long time, oil for constipation) *Return flow - harris flush to expel flatus and abdominal distention (fluid is returned to the bag from whence it came) |
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Name some types of retention enemas. |
*Oil-retention - lubricate the stool and intestinal mucosa easing defecation *Carminative - help expel flatus from rectum (milk of molasses) *Medicated - provide medications absorbed through rectal mucosa *Anthelmintic - destroy intestinal parasites *Nutritive - administer fluids and nutrition rectally (rarely done). |
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What are some bowel training programs and who are they for? |
For surgery patients, severe constipation, spinal cord injuries, quadriplegics *Manipulate factors within the patients control - food, fluid, exercise, time for defecation *Goal is to eliminate a soft, formed stool at regular intervals without laxatives *When achieved, discontinue use of suppository if one was used |
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Name the types of colostomies |
*Sigmoid *Descending *Transverse *Ascending *Ileostomy |
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How to care for a colostomy |
*Keep patient as free of odors as possible by emptying appliance often *Inspect stoma regularly - note size, keep skin around stoma site clean and dry *If stoma is dark purple this indicates ischemia to area. If stoma is pale this indicates anemia |
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Patient teaching for colostomies |
*Community resources available for assistance *Initially encourage to avoid food high in fiber *Avoid foods that cause diarrhea or flatus (alcohol, carbonation, all cabbage family, gum) *Odor control w/ ingestion of dark green veggies *Resume normal activities (work and sex) *Nuts, coconut, seedy material, dried fruit block stoma *Cheese, bland foods, applesauce, bananas help with diarrhea |
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What organs make up the urinary system? |
*Kidneys *Ureters *Bladder *Urethra |
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How do the kidneys and ureters function? |
*Maintain composition and volume of body fluids *Filter and excrete blood constituents not needed and retain those that are *Excrete waste products (urine) *Nephrons is the basic functional unit of kidney |
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How does the bladder function? |
*Smooth muscle sac serves as temp urine reservoir *Distends and puts pressure on muscle tissue. W/ enough pressure signals are sent to bladder to empty *Composed of three layers of muscle tissue called detrusor muscle *Sphincter guards opening between urinary bladder and urethra |
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How does the urethra function? |
*Urethra conveys urine from bladder to exterior of body *Male urethra functions in excretory and reproductive systems *Male urethra is 5 1/2 to 6 1/4inches *Female urethra is 1 1/2 to 2 1/2 inches |
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Describe the act of micturition |
*Process of emptying bladder *Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra *Muscles of perineum & external sphincter relax *muscles of abdominal wall contract slightly *Diaphragm lowers, micturition occurs *Voluntary but can be learned *Feel urge to void with 150-250mL in bladder |
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Describe some developmental considerations affecting micturition. |
*Children - toilet training (voluntary control) 18-24 months, enuresis (bed wetting until 6-8yrs) *Effects of aging - nocturia due to an inability to concentrate urine, increased frequency due to loss of muscle tone of bladder, urine retention and stasis due to loss of muscle tone, voluntary control affected by physical issues (neuromuscular problems, weakness) |
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What is urge incontinence? |
Have the urge to go but cannot hold it. Have to go immediately. |
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Name some effects of medications on urine production and elimination. |
*diuretics - prevent reabsorption of water and certain electrolytes in tubules *Cholinergic meds - stimulate contraction of detrusor muscle, producing urine *Analgesics and tranquilizers - suppress CNS, diminish effectiveness of neural reflex |
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Name some meds that affect the color of urine. |
*Anticoags - red urine b/c hematuria *Diuretics - pale yellow b/c diluted *Pyridium - orange to orange/red urine *Elavil - Green or blue-green *Levodopa - brown or black urine b/c of iron |
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Name some physical assessments of urinary function. |
*Kidneys - check for costovertebral tenderness *Bladder - palpate and percuss the bladder or use bedside scanner *Urethral meatus - inspect for signs of infection, discharge, or odor *Skin - assess for color, texture, turgor, and excretion of wastes *Urine - assess for color, odor, clarity, and sediment |
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How do nurses measure urine output? |
*Ask patient to void in bed pan, urinal, or specimen container in bed or bathroom. *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 |
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Name some types of urine specimen collections |
*Routine UA - no need for sterility (need 10mL) *Specimens from infants and children *Clean - catch or midstream (for C&S need 3mL) *Sterile specimens from indwelling caths *24hr urine specimen |
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What is a urinometer and how does it work? |
Measures urine specific gravity which looks at the density/concentration of urine *Device will float in urine if it is concentrated (high specific gravity) *Will sink in urine if urine is dilute (low specific gravity) |
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What is a normal I and O difference in 24hours? |
up to 300mL difference in I and O is normal |
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How can nurses promote normal urination? |
*Maintain normal voiding habits - answer call bells and provide privacy *Promote fluid intake - 8-10 glasses/day *Strengthening muscle tone - Keagles *Stimulating urination and resolving urinary retention - void as soon as you feel the urge |
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How to maintain normal voiding habits? |
*Schedule *Privacy *Position *Hygiene |
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What patients are at risk for UTIs? |
*Sexually active women *Postmenopausal women - increased urinary stasis, decreased estrogen causes loss of protective vag flora *Individuals with indwelling caths - 1/2 of all foley cath patients get a UTI w/I 7 days *Diabetes - increase sugar in urine with promotes bacterial growth *Elderly people |
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what are some reasons for urinary catheterization |
*relieving urinary retention *Obtaining a sterile urine specimen *Measuring amount of PVR urine in bladder *Obtaining a urine specimen when usual methods cannot be used *Emptying bladder before, during, or after sx *Monitoring critically ill patients |
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Patient education for urinary diversion |
*Explain reason for diversion and rationale for treatment *Demo effective self-care behaviors *Describe follow-up care and support resources *Report where supplies may be obtained in community *Verbalize related fears and concerns *Demonstrate a positive body image |
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What is a urinary diversion? |
Ureters are attached to section of bowel and attached to skin stoma *For obstruction or bladder cancer patients |
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What are some types of urinary incontinence |
*Stress - increase in intra-abdominal pressure (cough or sneeze) *Urge - urine lost during abrupt and strong desire to void (common with diuretics) *Mixed - urge and stress incontinence present *Overflow- over distension and overflow of bladder (not getting signal that full) *Functional - caused by factors outside the urinary tract (no bathroom, confusion) *Reflex - emptying bladder without sensation of need to void (spinal cord inj) *Total - continuous, unpredictable loss of urine (trauma, sx) |
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What are some factors to consider with use of absorbent products (urinary). |
*Increased risk for skin breakdown *Functional disability of the patient *Type of severity of incontinence *Gender *Availability of caregivers *Failure with previous treatment programs *Patient preference |
