EXAM 4 chapter 48 Urinary elimination

examples of common nursing dx in patients with urinary elimination problems

-Functional urinary incontinence -Stress urinary incontinence -Urge urinary incontinence -Risk for infection -Toileting self-care deficit -Impaired skin integrity -Impaired urinary elimination -Urinary retention

_____, _____, _____, and _____ syndromes can interfere with timely access to a toilet.

-arthritis -parkinson's disease - dementia -chronic pain

_____, _____, and _____ can alter bladder contractility in addition to the ability to sense bladder filling. Patients will experience either bladder overactivity or deficient bladder emptying.

-diabetes mellitus -multiple sclerosis -stroke

4 primary areas for physical assessment for urinary elimination include

-kidneys -bladder -genitalia and urethral meatus -perineal skin

3 nursing responsibilities after testing a patient

1. assess I&O 2. assess voiding and urine 3. encourage fluid intake

2 important categories of evaluation for urinary elimination

1. assessing the pts self-image, social interactions, sexuality, and emotional status 2. patient outcomes - determine if interventions were effective and evaluate voiding pattern

3 key points to ensure safe, individualized care for patients 1. follow principles of _____ 2. identify patient at risk for _____ 3.identify patient with allergies to _____ and provide alternatives like _____

1. follow principles of asepsis 2. identify patients at risk for latex allergy 3. identify patients with allergies to Betadine and provide alternatives like CHG

3 important categories that relate to planning

1. goals and outcomes (realistic) 2. setting priorities 3. teamwork and collaboration

successful critical thinking requires synthesis of (5)

1. knowledge 2. experience 3. info from patients 4. critical thinking attitudes 5. intellectual and professional standards

2 key interventions to prevent infection with catheters

1. maintain a closed urinary drainage system 2. prevention of urinary back flow from the tubing and bag into the bladder

4 important categories that relate to health promotion (implementation) in urinary elimination

1. patient education 2. promoting normal micturition (maintain elimination habits and adequate fluid intake) 3. promoting complete bladder emptying 4. preventing infection

4 nursing responsibilities before testing a patient

1. signed consent 2. assess pt allergies 3. admin bowel-cleansing agents as ordered 4. ensure pt adheres to diet (NPO)

2 alternatives to catheritaztion

1. suprapubic catheters 2. external catheters

5 parts that make up the assessment process

1. through the pts eyes 2. self-care ability 3. cultural considerations 4. health literacy 5. nursing history (pattern of urination & symptoms of urinary alterations)

-with an indwelling catheter should use a size _____ Fr (in adults) to minimize trauma and risk for infection. -Smaller sizes are needed for children such as a _____ Fr (in infants) -_____Fr for children, and 12 Fr for young girls.

14 to 16 Fr 5 to 6 Fr 8 to 10 Fr

Children cannot voluntarily control voiding until ___ to ___ months.

18 to 24 months

Most urine specimens need to reach the laboratory within _____ hours of collection or must be preserved according to laboratory protocol.

2 hours

Indwelling catheters come in a variety of balloon sizes from _____ mL (for a child) _____ mL for continuous bladder irrigation (CBI). The size of the balloon is usually printed on the catheter port. _____mL (for a adult) the balloon is 5 mL and requires _____ mL to fill completely

3 mL = child 30 mL = continuous bladder irrigation (CBI) 10 mL = adults 10 mL to fill

The pouch should be changed every __ to __ days. Each pouch may be connected to a bedside drainage bag for use at night.

4 to 6 days

When the bladder fills to approximately _____ to _____, most people experience a strong sensation of urgency.

400-600 mL

In many institutions, patients receive catheter care every _____ hours as the minimal standard of care.

8 hours

A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would this type of procedure would benefit from this procedure? A. An abdominal trauma victim B. A renal failure client C. A client with kidney stones D. An individual suffering from a urinary tract infection

A. An abdominal trauma victim Rationale: The abdominal trauma victim is the only appropriate answer here. The remaining problems can be treated with less traumatic care measures.

The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes: A. Avoid tight-fitting pants or clothing B. Drink six glasses of water per day C. Type of soap when bathing has no significance in this area. D. Voiding pattern in the course of the day has no significance with this problem.

A. Avoid tight-fitting pants or clothing Rationale: Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2-3 hours) to flush bacteria out other the urethra and prevent organisms from ascending into the bladder.

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A. Leaves the catheter in place and gets a new sterile catheter. B. Leaves the catheter in place and asks another nurse to attempt the procedure. C. Removes the catheter and redirects it to the urinary meatus. D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

A. Leaves the catheter in place and gets a new sterile catheter. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/day C. History of antihistamine intake D. History of frequent urinary tract infections E. fecal impaction

A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/day D. History of frequent urinary tract infections E. fecal impaction Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment.

The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly? A. Stopping urination midstream B. Standing tall and stretching out her arms and touching her toes C. Emptying her bladder completely D. Moving her bowels

A. Stopping urination midstream Rationale: Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner.

A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the: A. bladder. B. kidney. C. nephron. D. ureter.

Answer C

A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. large amounts of voided cloudy urine. B. pain in the suprapubic region. C. spasms and difficulty during urination. D. small amounts of urine voided two to three times per hour

Answer D

A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding: A. in bathrooms other than their own. B. in a urinal. C. while lying in bed. D. in the presence of a person other than one of their parents.

Answer D

_____: treat urgency, frequency, nocturia and urgency UI

Antimuscarinics

Which action represents the appropriate nursing management of a client wearing a condom catheter? A. Ensure that the tip of the penis fits snugly against the end of the condom. B. Check the penis for adequate circulation 30 minutes after applying. C. Change the condom every 8 hours. D. Tape the collecting tubing to the lower abdomen.

B. Check the penis for adequate circulation 30 minutes after applying. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is taped to the lower abdomen or upper thigh. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation.

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? A. Ileal conduit B. Kock pouch C. Neobladder D. Vesicostomy

B. Kock pouch Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment.

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. A. Voids each time there is an urge. B. Practices slow, deep breathing until the urge decreases. C. Uses adult diapers, for "just in case." D. Drinks citrus juices and carbonated beverages. E. Performs pelvic muscle exercises.

B. Practices slow, deep breathing until the urge decreases. E. Performs pelvic muscle exercises. Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation.

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. A. Limit fluids to avoid the burning sensation on urination. B. Review symptoms of UTI with the client. C. Wipe the perineal area from back to front. D. Wear cotton underclothes. E. Take baths rather than showers.

B. Review symptoms of UTI with the client. D. Wear cotton underclothes. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation.

_____: treat urinary retention _____: treat urinary tract infections

Bethanechol Antibiotics

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? A. "I will keep the collecting bag below the level of the bladder at all times." B. "Intake of cranberry juice may help decrease the risk of infection." C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." D. "I should use clean technique when emptying the collecting bag."

C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment nonconducive to infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods. B. Bladder training: delay voiding according to a preschedule timetable. C. Credé's maneuver: apply gentle manual pressure to the lower abdomen. D. Kegel exercises: contract the pelvic muscles.

C. Credé's maneuver: apply gentle manual pressure to the lower abdomen. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation.

A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated? A. Acute renal failure B. Renal stone C. Urinary tract infection D. Chronic renal failure

C. Urinary tract infection Rationale: The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed.

_____ are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs

Catheter-associated UTIs (CAUTIs)

The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? A. Having the client drink up to 3000mL per day B. Encouraging the client to eat foods that increase the acid in the urine C. Routine hygienic care D. Changing indwelling catheters every 72 hours.

D. Changing indwelling catheters every 72 hours. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy.

Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: A. Bladder training B. Habit training C. Prompted voiding D. Fluid restriction

D. Fluid restriction Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhinbit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void.

Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? A. Client self-care abilities B. Distance and barriers to accessing the bathroom C. Need/use of ambulatory aids as required D. No dietary restrictions needed

D. No dietary restrictions needed Rationale: Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide, and are appropriate measures to use with clients.

A practice guideline for nurses to use in preventing catheter-associated urinary infection includes which of the instructions listed below? A. Maintain clean technique when inserting the catheter into the client. B. Disconnect the catheter and drainage tubing once a shift to rinse the unit in cleaning the device. C. Since you are wearing gloves, it is not necessary to wash your hands. D. Prevent contamination of the catheter with feces in the incontinent client.

D. Prevent contamination of the catheter with feces in the incontinent client. Rationale: Keeping the perineal area free of feces eliminates the possible spread of any bacteria that may colonize in the feces and travel up the catheter to the bladder. Sterile or aseptic technique is used when inserting Foley catheters into clients to prevent the spread of infection with the process. Catheter tubing should not be disconnected once put into use. Connections are usually taped to help secure their seal. Wearing gloves with this procedure is part of the practice of Universal Precautions utilized when health care workers come in contact with most tubes and body fluids.

An appropriate health goal for clients with urinary elimination problems would include: A. Ignoring normalization of voiding pattern. That the patient has the ability to void is the most important aspect of care. B. Encouraging the client to follow measures to show a larger than normal urine output to flush to kidneys C. Always assisting the client with toileting activities in order to monitor amount D. Preventing associated risks, such as infections and fluid and electrolyte imbalances.

D. Preventing associated risks, such as infections and fluid and electrolyte imbalances. Rationale: Preventing associated risks related to urinary disease is the only appropriate goal noted.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A. The bladder distends and its capacity increases. B. Older adults ignore the need to void. C. Urine becomes more concentrated. D. The amount of urine retained after voiding increases.

D. The amount of urine retained after voiding increases. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment.

Urinary catheterization is carried out for clients only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? A. A client having abdominal surgery B. A client who is completely paralyzed C. A client in need of decompression of the bladder D. To collect a random urine specimen for evaluation

D. To collect a random urine specimen for evaluation Rationale: Collection of a random urine specimen is not routinely obtained by use of the process of catheterization. The other candidates/situations are appropriate uses of this technique.

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A. Stress Urinary Incontinence B. Reflex Urinary Incontinence C. Functional Urinary Incontinence D. Urge Urinary Incontinence

D. Urge Urinary Incontinence Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Diagnosis.

_____ are designed for indwelling catheters, provide one lumen for urinary drainage while a second lumen is used to inflate a balloon that keeps the catheter in place.

Double-lumen catheters

Urinary tract infections (UTIs) are usually caused by _____.

E. Coli

The size of a urinary catheter is based on the _____scale which reflects the internal diameter of the catheter.

French (Fr) scale

_____ assists the patient in understanding and participating in self-care practices to preserve and protect healthy urinary system function. You can achieve this focus using several means.

Health promotion

the assessment of urine includes measuring the patient's _____ and _____

I&O and characteristics of urine (color, clarity, odor)

_____reflex normally produces a series of contractions of the urinary bladder

Micturition

_____catheters are used for intermittent/straight catheterization

Single-lumen catheters (i.e., the insertion of a catheter for one-time bladder emptying)

_____: relax smooth muscle _____: shrink the prostate

Tamsulosin and silodosin Finasteride and dutasteride

_____catheters are used for continuous bladder irrigation or when it becomes necessary to instill medications into the bladder.

Triple-lumen catheters

Results from catheterization or procedure

UTI

_____ is the placement of a tube through the urethra into the bladder to drain urine. This is an invasive procedure that requires a medical order and in institutional settings, aseptic technique.

Urinary catheterization

____ is a basic body function and carries with it a variety of psychological and physiological needs.

Urinary elimination

Alcohol decreases the release of _____ hormones, thus increasing urine production.

antidiuretic

what influences bladder fxn

brain structures

CAUTI

catheter associated urinary tract infection

-Several areas in the brain are involved in bladder control (4) -There are two micturition centers in the spinal cord; one that coordinates inhibition of bladder _____ and the other that coordinates bladder _____.

cerebral cortex, thalamus, hypothalamus and brainstem. concentration and contractility

There are two types of irrigation: 1. _____ provides intermittent or continuous irrigation of the urinary catheter without disrupting the sterile connection between the catheter and the drainage system.

closed catheter irrigation

_____ independence and _____ interventions to help the patient achieve the desired outcomes and goals. The _____ activities are those in which nurses use their own judgment.

complete; collaborative; independent

_____reservoir is created from a distal portion of the ileum and proximal portion of the colon.

continent urinary reservoir

You assess for kidney tenderness by gently percussing the _____ angle

costovertebral

The _____process focuses on a specific urinary elimination alteration or an associated problem such as impaired skin integrity related to urinary incontinence.

diagnosis

voiding techniques are commonly referred to as behavioral therapy and are considered the _____ treatment for stress, urge, and mixed incontinence. They include: (4)

first- line treatment -lifestyle changes -pelvic floor muscle training (PFMT) -bladder retraining -toileting schedules

Building a relationship of trust with patients is important because the _____ of care involves interaction of a very personal nature.

implementation

If fluids, electrolytes, and solutes are balanced, fluid intake _____ and urine production _____.

increases; increases

Patients with acute illness, surgery or impaired function of the urinary tract may require _____ that support urinary elimination.

interventions

To maintain the patency of indwelling urinary catheters, it is sometimes necessary to

irrigate or flush a catheter with sterile solution

In order to obtain urine as free of bacterial contamination as possible, a _____ clean catch urine specimen may be required.

midstream

-are small tubes tunneled through the skin into the renal pelvis -drains the renal pelvis when the ureter is obstructed

nephrostomy tubes

A thorough assessment of a patient's urinary elimination function reveals patterns of data that allow a nurse to make relevant and accurate _____.

nursing diagnoses

The second type of continent urinary diversion is called an _____ , which uses an ileal pouch to replace the bladder.

orthotopic neobladder

Kegel exercises teach patients how to contract the _____

pelvic floor muscles

During _____ integrate the knowledge from assessment and information about available resources and therapies to develop an individualized plan of care.

planning

Anxiety can impact bladder emptying due to inadequate _____ of the pelvic floor muscles and urinary sphincter.

relaxation

The only drainage bag that does not need to be kept dependent to the bladder is a _____

specially designed drainage bag (belly bag) - that is worn across abdomen

_____injury or _____disease can cause the loss of urine control due to bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter.

spincal cord injury (above S-1) or intervetebral disk disease

The most common urinary elimination problems involve the inability to _____ -Problems can result from infection, irritable or overactive bladder, obstruction of urine flow, impaired bladder contractility, or issues that impair innervation to the bladder resulting in sensory or motor dysfunction.

store urine or fully empty urine from the bladder

As the bladder fills and stretches, bladder contractions are inhibited by _____ stimulation from the thoracic micturition center.

sympathetic

An accumulation of urine due to the inability of the bladder to empty

urinary retention

bladder concentration + urethral sphincter and pelvic floor muscle relaxation =

voiding