1200 Test 3

Renal Calculi: Nursing diagnosis

Acute pain Anxiety r/t uncertain outcome Ineffective therapeutic regimen management Impaired urinary elimination Risk for infection

Nursing Diagnosis

Acute pain related to inflammation, obstruction, and abrasion of the urinary tract Deficient knowledge regarding prevention of recurrence of renal stones Here are four nursing diagnosis for Urolithiasis (renal calculi):  Acute Pain Impaired Urinary Elimination Risk for Deficient Fluid Volume Deficient Knowledge

Nursing Priorities

Alleviate pain. Maintain adequate renal functioning. Prevent complications. Provide information about disease process/prognosis and treatment needs.

Enemas

Cleansing enemas Tap water Normal saline Hypertonic solutions Soapsuds Oil retention Others types of enemas Carminative and Kayexalate

What causes disorders of the bowel

Elimination dysfunction: constipation, diarrhea, gastroenteritis, Irritable Bowel Syndrome Mechanical dysfunction: tumors, polyps, fistulas, hernias, diverticulosis Malabsorption: Chron's disease, inflammatory bowel disease, Celiac disease, Lactose intolerance Inflammation: Chron's disease, Inflammatory bowel disease, Appendicitis, Peritonitis, Ileus, Diverticulitis Infection: Bacterial infection (Clostridium difficile, Salmonella, Ercheria coli) & parasitic (Giardiasis, round worms)

Collaborative Problems/Potential Complications

Infection and urosepsis (from urinary tract infection and pyelonephritis) Obstruction of the urinary tract by a stone or edema, with subsequent acute renal failure

Nursing Interventions

Relieving Pain Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed. Encourage and assist patient to assume a position of comfort. Assist patient to ambulate to obtain some pain relief. Monitor pain closely and report promptly increases in severity.

Consequences of un treated pain

Unnecessary suffering Physical and psychosocial dysfunction Immunosuppression Sleep disturbances

Renal Calculi removal: LIthotrispy

asive Lithotripsy Percutaneous ultrasonic lithotripsy - via percutaneous nephroscope Electrohydraulic lithotripsy - percutaneous Laser lithotripsy probes - lower ureteral and large bladder stones Non-invasive - Extracorporeal shock-wave lithotripsy Patient is anesthetized High-energy acoustic shock waves shatter stone without damaging surrounding tissue

Goals and Outcomes

he following are the common goals and expected outcomes for Impaired Urinary Elimination: Patient demonstrates behaviors and techniques to prevent retention/urinary infection. Patient identifies the cause of incontinence. Patient maintains balanced I&O with clear, odor-free urine, free of bladder distension/urinary leakage. Patient provides rationale for treatment. Patient verbalizes understanding of the condition.

Dimensions of Pain Affective

Emotional response to pain experience Anger Fear Depression Anxiety Suffering: State of severe distress associated with loss Eased by pain relief Influenced by spirituality Suffering can result in a profound sense of insecurity and lack of control, and spiritual distress. Achieving pain relief is one essential step in relieving suffering. It is important to assess the ways in which a person's spirituality influences and is influenced by pain. Negative emotions impair the patient's quality of life.

Factors effecting bowel elimination

Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern. Age influences bowel elimination. Infants have a smaller stomach capacity, less secretion of digestive enzymes, and more rapid intestinal peristalsis. The ability to control defecation does not occur until 2 to 3 years of age. Adolescents experience rapid growth and increased metabolic rate. There is also rapid growth of the large intestine and increased secretion of gastric acids to digest food fibers and act as a bactericide against swallowed organisms. Older adults may have decreased chewing ability. Peristalsis declines and esophageal emptying slows. Factors that affect bowel elimination for the older client are decreased peristalsis, dehydration and loss of muscle tone in the perineal floor. This impairs absorption by the intestinal mucosa. Muscle tone in the perineal floor and anal sphincter weakens, and may cause difficulty in controlling defecation. Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber in the diet provides the bulk in the fecal material. Bulk-forming foods help remove the fats and waste products from the body. Some foods may also produce gas, which distends the intestinal walls and increases colonic motility. While individual fluid needs vary with the person, a fluid intake of 3 L per day for men and 2.2 L per day for women is recommended. Fluid liquefies intestinal contents by absorbing into the fiber from the diet and creating a larger, softer stool mass. This increases peristalsis and promotes movement of stool through the colon. Physical activity promotes peristalsis. Prolonged emotional stress impairs the function of almost all body systems. During emotional stress, the digestive process is accelerated and peristalsis is increased. Personal elimination habits influence bowel function. A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation. Squatting is the normal position during defecation. For the patient immobilized in bed, defecation is often difficult. If the patient's condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate. A number of conditions such as hemorrhoids, rectal surgery, anal fissures (which are painful linear splits in the perianal area), and abdominal surgery result in discomfort. In these instances, the patient often suppresses the urge to defecate to avoid pain, contributing to the development of constipation. As pregnancy advances, the size of the fetus increases and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs passage of feces. Slowing of peristalsis during the third trimester often leads to constipation. A pregnant woman's frequent straining during defecation or delivery may result in formation of hemorrhoids. General anesthetic agents used during surgery cause temporary cessation of peristalsis. The patient who receives a local or regional anesthetic is less at risk for elimination alterations because this type of anesthesia generally affects bowel activity minimally or not at all. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed. Many medications prescribed for acute and chronic conditions have secondary effects on the patient's bowel elimination patterns. Some medications are used primarily for their action on the bowel and will promote defecation such as laxatives or cathartics or control diarrhea. Diagnostic examinations involving visualization of GI structures often require a prescribed bowel preparation (e.g., laxatives, and/or enemas) to ensure that the bowel is empty. Usually, the patient cannot eat or drink several hours before examinations such as an endoscopy, colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern.

Benign Prostatic Hyperplasia (BPH)

One of the most common diseases in aging men. The enlargement, or hypertrophy, of the prostate gland. The prostate gland enlarges, extending upward into the bladder and obstructing the outflow of urine. Incomplete emptying of the bladder and urinary retention leading to urinary stasis may result in hydronephrosis, hydroureter, and urinary tract infections (UTIs). The cause is not well understood, but evidence suggests hormonal involvement. BPH is common in men older than 40 years. It can cause bothersome lower urinary tract symptoms that affect quality of life by interfering with daily normal activities and sleep pattern.

Ostomies

Sigmoid colostomy Transverse colostomy Ileostomy Loop colostomy End colostomy

Etiology

Slow urine flow allows accumulation of crystals—damaging the lining of the urinary tract and decreasing the number of inhibitor substances that would prevent crystal accumulation (Winkleman, 2006). May remain asymptomatic until passed into a ureter or urine flow is obstructed, at which time the potential for renal damage is acute and the level of pain is at its highest. Causes: dehydration; heredity; excessive intake of vitamins C and D, grapefruit juice, and purines (gout); congenital renal abnormalities; and some medications, such as acetazolamide (Diamox) or indinavir (Crixivan)

Nursing care plan and goals of BPH

The goals for a patient with BPH include: Relieve acute urinary retention. Promote comfort. Prevent complications. Help patient deal with psychosocial concerns. Provide information about disease process/prognosis and treatment needs.

Nursing Roles

Assess pain and communicate with other health care providers Ensure initiation of adequate pain relief measures Evaluate effectiveness of interventions Advocate for those in pain

Nursing Diagnoses BPH

Based on the assessment data, the appropriate nursing diagnoses for a patient with BPH are: Urinary retention related to obstruction in the bladder neck or urethra. Acute pain related to bladder distention. Anxiety related to the surgical procedure.

Renal calculi: Manifestations & Diagnosis

Clinical Manifestation: Abdominal or flank pain Hematuria "Renal Colic" - passing into the ureter Nausea & vomiting Chills, fever Diagnosis: UA, Urine C&S, IVP, retrograde pyelogram, ultrasound, cystoscopy Renal function: BUN, Serum Creatinine

Definition of pain

"Whatever the person experiencing pain says it is, existing whenever the person says it does." Margo McCaffery "Unpleasant sensory and emotional experience associated with actual or potential tissue damage." IASP Pain was originally defined in 1968 by Margo McCaffery, a nurse and pioneer in pain management. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Note that these definitions emphasize the subjective nature of pain, in which the patient's self-report is the most valid means of assessment. Subjective: Patient's experience and self-report are essential Can be problematic when dealing with special populations (coma or dementia) Nonverbal information such as behaviors aids the assessment of pain Patients who are comatose or who suffer from dementia, patients who are mentally disabled, and patients with expressive aphasia possess varying ability to report pain. In these instances, you must incorporate nonverbal information such as behaviors into your pain assessment.

Safety Guideines for nursing skills

Follow principles of surgical and medical asepsis as indicated Identify patients at risk for latex allergies Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

Physical Assessment

Physical assessment Kidneys Bladder External genitalia and urethral meatus Perineal skin

Bowel training Maintenance of proper fluid and food intake Promotion of regular exercise Management of the patient with fecal incontinence or diarrhea Maintenance of skin integrity

The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient may have a normal defecation pattern. [Review Box 47-13, Focus on Older Adults: Bowel Retraining, with students.] In choosing a diet for promoting normal elimination, consider the frequency of defecation, characteristics of feces, and types of foods that impair or promote defecation. A well-balanced diet with whole grains, legumes, fresh fruits and vegetables eaten regularly promotes normal elimination. Fiber adds bulk to the stool, eliminates excess fluids and promotes more frequent and regular movements. With increasing fiber it is important to drink enough fluids. When the patient has diarrhea, low residue foods, such as white rice, potatoes, bread, bananas, and cooked cereals, are recommended until the diarrhea is controlled. If the patient cannot tolerate foods or liquids orally, intravenous therapy with electrolyte replacement is necessary. [Ask students: Why is it important to drink fluids when increasing fiber intake? Discuss: If fluid intake is inadequate, the stool becomes hard because less water is retained in the large intestine to soften the stool.] A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. It is recommended by the American Heart Association and the Centers for Disease Control that adults get at least 150 minutes of exercise each week. For a patient temporarily immobilized, attempt ambulation as soon as possible. In the management of the patient with fecal incontinence or diarrhea, a fecal collector may be applied around the anal opening if the skin is intact. Fecal management systems are available for short-term use with high-volume diarrhea. They are intended for use primarily in acute care settings. The patient with diarrhea, fecal incontinence, or an ileostomy is at risk for skin breakdown when fecal contents remain on the skin. Liquid stool usually contains digestive enzymes that can cause rapid skin breakdown. Irritation from repeated wiping with toilet tissue or frequent ostomy pouch changes further irritates the skin. Meticulous perianal skin care and frequent removal of fecal drainage is necessary to prevent skin breakdown. Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. If the patient is incontinent, the patient must have be checked frequently and have an immediate change of absorbent products in addition to thorough, but gentle skin cleansing. Patients with ostomies may be unaware of the skin irritation under their ostomy wafer or think that this is a normal part of having an ostomy. Education about skin breakdown and management of it if it does occur is an important role for the ostomy nurse.

Implementation: Continuing and restorative care Lifestyle changes Pelvic floor muscle training Bladder retraining Toileting schedules Intermittent catheterization Skin care

There are techniques that can improve control over bladder emptying and restore some degree of urinary continence. These techniques are commonly referred to as behavioral therapy and are considered first- line treatment for stress, urge, and mixed incontinence. They include lifestyle changes, pelvic floor muscle training (PFMT), bladder retraining, and a variety of toileting schedules In some cases, when the bladder does not empty, patients or caregivers learn to intermittently catheterize. Whenever there is a risk for urine leakage, skin care is an essential component of the plan of care. Adequate urine containment and skin protection promotes patient comfort and dignity. Teach patients about foods and fluids that cause bladder irritation and increase symptoms such as frequency, urgency, and incontinence. Teach patients to avoid common irritants such as artificial sweeteners, spicy foods, citrus products, and especially caffeine. Encourage patients with edema to elevate the feet for a minimum of a few hours in the afternoon to help diminish nighttime voiding frequency. Pelvic floor muscle training (PFMT) involves teaching patients how to identify and contract the pelvic floor muscles in a structured exercise program. This exercise program is commonly called "Kegel" exercises and is based upon therapy first developed by obstetrician gynecologist Dr. Arnold Kegel in the 1940s. The exercises work by increasing the pressure within the urethra by strengthening the pelvic floor muscles and by inhibiting unwanted bladder contractions. In bladder retraining, patients are taught about their bladder and techniques to suppress urgency. They are given a schedule of toileting based upon their diary of voiding and leaking and a schedule is designed to slowly increase the interval between voiding. Patients are taught to inhibit the urge to void by taking slow and deep breaths to relax, perform five to six quick strong pelvic muscle exercises (flicks) in quick succession followed by distracting attention from bladder sensations. When the urge to void becomes less severe or subsides, only then should the patient start their trip to the bathroom. Timed voiding or scheduled toileting is toileting based upon a fixed schedule, not the patient's urge to void. The schedule maybe set by a time interval, every two to three hours or at times of day such as before and after meals. Habit training is a toileting schedule based upon the patient's usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. Prompted voiding is a program of toileting designed for patients with mild or moderately cognitive impairment. Patients are toileted based upon their usual voiding pattern. Caregivers ask the patient if they are wet or dry, give positive feedback for dryness, prompt the patient to toilet, and reward the patient for desired behavior. Some patients experience chronic inability to completely empty the bladder due to neuromuscular damage. To minimize the risk of urinary tract infection, patients or caregivers are taught to catheterize the bladder. In institutions and catheterization in any setting by a health care provider, intermittent catheterization should follow the principles of asepsis as discussed earlier in the chapter. Teach patients and caregivers about the importance of adequate fluid intake, signs of infection, and their individualized catheterization schedule. The goal for intermittent catheterization is drainage of 400 mL of urine with the schedule is individualized to meet this goal. Key components for incontinence associated dermatitis prevention and treatment include gentle skin cleansing with a no-rinse pH-balanced cleanser, using a skin moisturizer, and application of a moisture-barrier product. In some cases, patients may develop a topical fungal infection that requires treatment with a steroid/antifungal cream or ointment. [Shown is Figure 46-16: Pelvic floor muscles. (From Lewis S, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St Louis, 2014, Mosby.)]

Renal Calculi: Nursing Management

Assess: Pain—guarding, pain scale, occurrence—colic versus ongoing, tenderness on palpation; History: recent/chronic UTI, immobility, gout, hyperparathyroidism, prostatic hyperplasia; family history of calculi; urine output; oliguria, hematuria; labs—BUN, CR, UA, Urine C&S, Increased uric acid, calcium Action: Relieve pain; Treat UTI; Admin meds; Force fluids PO - >2L/day; Maintain IV patency; strain urine; position of comfort Pt Education: Rationale for treatment; Measures to prevent future recurrence (once calculi origin is determined)—dietary restrictions (purine, calcium, oxalates

Assment and Diagnostic Methods

Diagnosis is confirmed by xrays of the kidneys, ureters, and bladder (KUB) or by ultrasonography, IV urography, or retrograde pyelography. Blood chemistries and a 24hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume. Chemical analysis is performed to determine stone composition.

Nursing managment of patient with BPH

Nursing assessment focuses on the health history of the patient. Health history. The health history focuses on the urinary tract, previous surgical procedures, general health issues, family history of prostate diseases, and fitness for possible surgery. Physical assessment. Physical assessment includes digital rectal examination.

Pharmacologic Therapy

Opioid analgesic agents (to prevent shock and syncope) and nonsteroidal antiinflammatory drugs (NSAIDs). Increased fluid intake to assist in stone passage, unless patient is vomiting; patients with renal stones should drink eight to ten 8oz glasses of water daily or have IV fluids prescribed to keep the urine dilute.

Diagnostic Studies

Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones). Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated. Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).

Renal Calculi Description

Urolithiasis refers to stones (calculi) in the urinary tract. Stones are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases. Stones vary in size from minute granular deposits to the size of an orange. Factors that favor formation of stones include infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism. The problem occurs predominantly in the third to fifth decades and affects men more often than women.

Opoid induced constipation STUDY SLIDE 99 ELIMINATION

Affects 40% of clients treated for chronic pain with opioids gastric emptying decrease peristalsis decrease fluid reabsorption increase sphincter tone Morphine, oxy, codeine Fentanyl and methadone cpg recommended drugs Lubiprostone (Amitiza) increases fluid secretion into bowel Naloxegol (Movantik) antagonizes morphine-induced delay in transit times (Narcan, naloxone

Nutritional Therapy

For calcium stones: reduced dietary protein and sodium intake; liberal fluid intake; medications to acidify urine, such as ammonium chloride and thiazide diuretics if parathormone production is increased. For uric stones: lowpurine and limited protein diet; allopurinol (Zyloprim). For cystine stones: lowprotein diet; alkalinization of urine; increased fluids. For oxalate stones: dilute urine; limited oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran).

Pain Mechanisms: Nocioception

Physiologic process that communicates tissue damage to the CNS Involves 4 processes: Transduction Transmission Perception Modulation Nociception involves four processes: (1) transduction, (2) transmission, (3) perception, and (4) modulation. Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses

Evaluation

Reduced anxiety. Reduced level of pain. Maintained fluid volume balance postoperatively. Absence of complications.

Evaluation

Through the patient's eyes Assess the patient's self-image, social interactions, sexuality, and emotional status Patient outcomes Use the expected outcomes developed during planning to determine whether interventions were effective Evaluate for changes in the patient's voiding pattern and/or presence of symptoms Evaluate patient/caregiver compliance with the plan

Physical Assessment

note: listen before touching...percussion & palpation can increase peristalsis

Magnitude of pain problem

25 million people experience acute pain from injury or surgery Chronic pain affects over a million American adults 60% of cancer patients experience pain during treatment Despite the prevalence of pain, many studies document inadequate pain management across care settings and patient populations For example, approximately one-third of patients enrolled in hospice reported pain at their last hospice visit. Cancer pain is often undertreated.

Renal Calculi

500,000 people in US annually 20-55 years of age More common in men than women Except for struvite stones associated with UTI No single theory can account for stone formation Urinary pH, solute load, urinary stasis, urinary infection with urea-splitting bacteria Five major categories: Calcium phosphate Calcium oxalate Uric acid Cystine Struvite

Implementation: Preventing catheter associated infection Catheter irrigations and instillations

A critical part of routine catheter care is reducing the risk for CAUTI. A key intervention to prevent infection is maintaining a closed urinary drainage system. Another key intervention is prevention of urine back flow from the tubing and bag into the bladder. Many urine drainage systems are equipped with an antireflux valve but the nurse should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder. [Review Box 46-9, Evidence Based Practice Factors to Decrease Urinary Tract Infections, with students.] [Review Box 46-10, Preventing CAUTI, with students.] To maintain the patency of indwelling urinary catheters, it is sometimes necessary to irrigate or flush a catheter with sterile solution. Generally, if a catheter becomes occluded, it is best to change the catheter rather than risk flushing debris into the bladder. Bladder instillations are used to instill medication into the bladder. Refer to specific instructions for these medications in terms of how long the medication needs to stay in the bladder. There are two types of irrigation: closed catheter irrigation and open irrigation. Closed catheter irrigation provides intermittent or continuous irrigation of the urinary catheter without disrupting the sterile connection between the catheter and the drainage system. [Review Skill 46-4, Catheter Irrigation, with students.] Continuous bladder irrigation (CBI) is an example of a continuous infusion of a sterile solution into the bladder, usually using a three-way irrigation closed system with a triple-lumen catheter. CBI is frequently used following genitourinary surgery to keep the bladder clear and free of blood clots or sediment. [Shown is Figure 46-14: Potential sites for introduction of infectious organisms into a urinary drainage system.]

Inserting and Maintaining a Nasogastric Tube Purposes Decompression, enteral feeding, compression, and lavage Categories of nasogastric (NG) tubes Fine- or small-bore for medication administration and enteral feedings Large-bore (12-French and above) for gastric decompression or removal of gastric secretions Clean technique Maintaining patency

A patient's condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery, obstruction of the GI tract often caused by tumors, trauma to the GI tract, and conditions in which peristalsis is absent. A nasogastric (NG) tube is a pliable hollow tube that is inserted through the patient's nasopharynx into the stomach. [Review Table 47-3, Purposes of Nasogastric Intubation, with students.] There are two main categories of NG tubes: Fine- or small-bore tubes and large-bore tubes. Small-bore tubes are frequently used for medication administration and enteral feedings. Large-bore tubes, 12-Fr and above, are usually used for gastric decompression or removal of gastric secretions. NG tube insertion does not require sterile technique. Clean technique is used. The procedure is uncomfortable. The patient experiences a burning sensation as the tube passes through the sensitive nasal mucosa. When it reaches the back of the pharynx, the patient sometimes begins to gag. Help the patient relax to make tube insertion easier. Some institutions allow the use of Xylocaine jelly or atomized lidocaine when inserting the tube because it decreases patient discomfort during the procedure. [Review Skill 47-2, Inserting and Maintaining a Nasogastric Tube for Gastric Decompression, with students.] After you insert the tube, you need to maintain its patency. Sometimes the tip of the tubing rests against the stomach wall or the tube becomes blocked with thick secretions. Flushing the tube regularly using a catheter tipped syringe filled with normal saline or warm water helps to prevent blockage of the tube. If an NG tube does not drain properly after flushing, reposition it by advancing or withdrawing it slightly. Any change in tube position requires you to verify its placement in the patient's GI tract.

Catheter drainage systems Routine catheterine care

An indwelling catheter is attached to urinary drainage bag to collect the continuous flow of urine. The drainage system should not be separated unless absolutely necessary to avoid introducing pathogens. In patients with indwelling catheters, specimens are collected without opening the drainage system using a special port in the tubing. Always hang the bag below the level of the bladder on the bed frame or a chair so that urine will drain down, out of the bladder. The bag should never touch the floor. When a patient ambulates, carry the bag below the level of the patient's bladder. Ambulatory patients may use a leg bag. 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 the abdomen. To keep the drainage system patent, check for kinks or bends in the tubing, avoid positioning the patient on drainage tubing, prevent tubing from becoming dependent, and observe for clots or sediment that may block the catheter or tubing. Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, to reduce the risk for CAUTI. In many institutions, patients receive catheter care every 8 hours as the minimal standard of care. [Review Skill 46-3, Indwelling Catheter Care, with students.] Empty drainage bags when half full. An overfull drainage bag can create tension and pull on the catheter resulting in trauma to the urethra and/or urinary meatus and increasing the risk for CAUTI. Expect continuous drainage of urine into the drainage bag. In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter. [Shown at top is Figure 46-12:Urine specimen collection: aspiration from a collection port in drainage tubing of indwelling catheter (needleless technique). (Courtesy and © Becton, Dickinson and Company.)] [Shown at bottom is Figure 46-13: Urine drainage bag.]

Nursing Process: Assessment

Assessment Assess for pain and discomfort, including severity, location, and radiation of pain. Assess for associated symptoms, including nausea, vomiting, diarrhea, and abdominal distention. Observe for signs of urinary tract infection (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). Assessment (cont.) Observe urine for blood; strain for stones or gravel. Focus history on factors that predispose patient to urinary tract stones or that may have precipitated current episode of renal or ureteral colic. Assess patient's knowledge about renal stones and measures to prevent recurrence.

Signs & Symptoms of BPH

BPH may or may not lead to lower urinary tract symptoms; if symptoms occur, they may range from mild to severe. Urinary frequency. Frequent trips to the bathroom to urinate may be an early sign of a developing BPH. Urinary urgency. This is the sudden and immediate urge to urinate. Nocturia. Urinating frequently at night is called nocturia. Weak urinary stream. Decreased and intermittent force of stream is a sign of BPH. Dribbling urine. Urine dribbles out after urination. Straining. There is presence of abdominal straining upon urination.

Current Statistics for BPH

BPH typically occurs in men older than 40 years of age. By the time they reach 60 years of age, 50% of men have BPH. BPH affects as many as 90% of men by 85 years of age. BPH is the second most common cause of surgical intervention in men older than 60 years of age.

Dimensions of pain

Biopsychosocial Model of Pain Physiologic Affective Cognitive Behavioral Sociocultural The biopsychosocial model of pain includes the physiologic, affective, cognitive, behavioral, and sociocultural dimensions of pain

Continuing Care

Closely monitor the patient to ensure that treatment has been effective and that no complications have developed. Assess the patient's understanding of ESWL and possible complications; assess the patient's understanding of factors that increase the risk of recurrence of renal calculi and strategies to reduce those risks. Assess the patient's ability to monitor urinary pH and interpret the results during followup visits. Ensure that the patient understands the signs and symptoms of stone formation, obstruction, and infection and the importance of reporting these signs promptly. If medications are prescribed for the prevention of stone formation, explain their actions, importance, and side effects to the patient.

Common Bowel elimination problems

Constipation is a symptom, not a disease, and there are many possible causes. Improper diet, reduced fluid intake, lack of exercise and certain medications can cause constipation. When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Constipation is a significant source of discomfort and the nurse should assess the need for intervention before the defecation becomes painful or the stool is impacted. [Review Box 47-1, Common Causes Of Constipation, with students.] Fecal impaction results from unrelieved constipation. In cases of severe impaction, the mass extends up into the sigmoid colon. If not resolved or removed, severe impaction can result in intestinal obstruction. Patients who are debilitated, confused, or unconscious are most at risk for impaction. The nurse should suspect an impaction when a continuous oozing of liquid stool occurs. The liquid portion of feces located higher in the colon seeps around the impacted mass. Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery and the patient may have difficulty controlling the urge to defecate. Excess loss of colonic fluid can result in dehydration with fluid and electrolyte or acid-base imbalances if the fluid is not replaced. Meticulous skin care and containment of fecal drainage is necessary to prevent skin breakdown. Some causes of diarrhea include Clostridium difficile, communicable foodborne pathogens, surgeries or diagnostic testing of the lower GI tract, and food intolerances. If a client has had an acute episode of diarrhea of undiagnosed origin and is experiencing dehydration and perianal excoriation, the following actions are helpful...maintain a strict record of intake and output, encourage fluid replacement with high electrolyte content and assume the diarrhea is infectious & initiate standard precautions. [Review Box 47-2, Signs of Dehydration, with students.] Fecal incontinence is the inability to control passage of feces and gas from the anus. Many conditions cause fecal incontinence or diarrhea and it is important to identify precipitating conditions and refer to health care providers for medication management. Hemorrhoids are dilated, engorged veins in the lining of the rectum and can be either external or internal. Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids.

Enema administration Sterile technique is unnecessary. Wear gloves. Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. Digital removal of stool Use if enemas fail to remove an impaction. Last resort in managing severe constipation.

Enemas are available in commercially packaged, disposable units or with reusable equipment prepared before use. Sterile technique is unnecessary because the colon normally contains bacteria. However, wear gloves to prevent the transmission of fecal microorganisms. Explain the procedure, including the position to assume, precautions to take to avoid discomfort, and length of time necessary to retain the solution before defecation. If the patient needs to take the enema at home, explain the procedure to a family member. Giving an enema to a patient who is unable to contract the external sphincter poses difficulties. Give the enema with the patient positioned on the bedpan. Giving the enema with the patient sitting on the toilet is unsafe because the position of the rectal tubing could injure the rectal wall. [Review Skill 47-1, Administering a Cleansing Enema, with students.] For a patient with an impaction, the fecal mass is sometimes too large to pass voluntarily. If a digital rectal exam reveals a hard stool mass in the rectum, it may be necessary to manually remove it by breaking it up and bringing out a section at a time. Digital removal should be the last resort in the management of severe constipation, but may be necessary if the fecal is too large to pass through the anal canal. The procedure is very uncomfortable for the patient. Excess rectal manipulation causes irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which could results in a reflex slowing of the heart rate. [Review Box 47-10, Procedural Guidelines: Digital Removal of Stool, with students.]

Acute care

Environment Cathartics and laxatives Cathartics have a stronger and more rapid effect on the intestines than laxatives Suppositories may act more quickly than oral medications Antidiarrheal agents Opiates used with caution Chronically ill and hospitalized patients are not always able to maintain privacy during defecation. In a hospital or extended care setting, patients sometimes share bathroom facilities with a roommate. In addition, chronic illness may limit a patient's mobility and activity tolerance and require the use of a bedpan or bedside commode. The sights, sounds and odors associated with sharing toilet facilities or using bedpans are often embarrassing. This embarrassment often causes patients to ignore the urge to defecate, which leads to constipation and discomfort. Be sensitive to patients' elimination needs and intervene to help them maintain as normal bowel elimination habits as possible. Laxatives and cathartics have the short-term action of emptying the bowel. These agents are also used to cleanse the bowel for patients undergoing GI tests and abdominal surgery. Although the terms laxative and cathartic are often used interchangeably, cathartics generally have a stronger and more rapid effect on the intestines. Although patients usually take medications orally, laxatives prepared as suppositories may act more quickly because of their stimulant effect on the rectal mucosa. Give the suppository shortly before the patient's usual time to defecate or immediately after a meal. Laxatives are classified by the method by which the agent promotes defecation. Clients should not be taking laxatives as a method to regulate bowel movements as in the future it will decrease the client's ability to regulate normal elimination. Fruit, fiber, and exercise help prevent constipation. Frequency of bowel movements varies between people. Normal bowel movements occur three times daily to three times a week. [Review Table 47-2, Common Types of Laxatives and Cathartics, with students.] Antidiarrheal agents decrease intestinal muscle tone to slow the passage of feces. As a result, the body absorbs more water through the intestinal walls. The most commonly used antidiarrheal agents are loperamide and diphenoxylate with atropine. Codeine or tincture of opium may be used for management of chronic severe diarrhea in patients with diseases such as Crohn's disease, ulcerative colitis, and acquired immunodeficiency syndrome (AIDS). Antidiarrheal agents that contain opiates must be used with caution because opiates are habit forming.

Teaching Points

Explain causes of kidney stones and ways to prevent recurrence. Encourage patient to follow a regimen to avoid further stone formation, including maintaining a high fluid intake. Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours. Recommend that patient have urine cultures every 1 to 2 months the first year and periodically thereafter. Recommend that recurrent urinary infection be treated vigorously. Encourage increased mobility whenever possible; discourage excessive ingestion of vitamins (especially vitamin D) and minerals. If patient had surgery, instruct about the signs and symptoms of complications that need to be reported to the physician; emphasize the importance of followup to assess kidney function and to ensure the eradication or removal of all kidney stones to the patient and family. If patient had ESWL, encourage patient to increase fluid intake to assist in the passage of stone fragments; inform the patient to expect hematuria and possibly a bruise on the treated side of the back; instruct patient to check his or her temperature daily and notify the physician if the temperature is greater than 38C (about 101F), or the pain is unrelieved by the prescribed medication. Provide instructions for any necessary home care and follow-up.

Renal Calculi: Nutritional Therapy

Foods high in purine, calcium, or oxalate: Purine: High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups sweetbreads Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham Calcium: milk, cheese, ice cream, yogurt, sauces containing milk, all beans (except green beans), lentils, fish with fine bones (sardines, kippers herring, salmon); dried fruits, nuts, chocolate, cocoa, Ovaltine Oxalate: spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans, chocolate, cocoa, instant coffee, Ovaltine, tea; Worcestershire sauce

Investigation

For NE, only urinalysis (including protein, nitrite and leucocytes) is necessary. If significant daytime wetting or UTI is present, an ultrasound scan of the kidneys and bladder is needed. Invasive investigations such as urodynamics or an intravenous urogram (computerized tomography (CT) of the bladder) are rarely needed.

Implementation: Urinary diversions Incontinent diversions Changing a pouch Gently cleanse the skin surrounding the stoma Measure the stoma and cut the opening in the pouch Remove the adhesive backing and apply the pouch Press firmly into place over the stoma. Observe the appearance of the stoma and surrounding skin. Continent diversions Orthopic neobladder

Immediately after surgery, the patient with an incontinent urinary diversion must wear a pouch to collect the effluent (drainage). The pouch will keep the patient clean and dry, protect the skin from damage and provide a barrier against odor. The pouch should be changed every 4 to 6 days. Each pouch may be connected to a bedside drainage bag for use at night. When changing a pouch, gently cleanse the skin surrounding the stoma with warm tap water using a washcloth and pat dry. Measure the stoma and cut the opening in the pouch. Then apply the pouch after removing the protective backing from the adhesive surface. Press firmly into place over the stoma. Observe the appearance of the stoma and surrounding skin. The stoma is normally red and moist and is located in the right lower quadrant of the abdomen. It is important for the patient to have the correct type and fit of an ostomy pouch. A specialty ostomy nurse is an essential resource when selecting the right appliance so that the pouch fits snugly against the skin's surface around the stoma preventing damaging leakage of urine. Patients with continent urinary diversions do not have to wear an external pouch. However, if the patient has a continent urinary reservoir, the patient must be taught how to intermittently catheterize the pouch. Patients will need to be able and willing to do this four to six times a day for the rest of their lives. After creation of an orthoptic neobladder, patients will have frequent episodes of incontinence until the neobladder slowly stretches and the urinary sphincter is strong enough to contain the urine. To achieve continence, the patient will need to follow a bladder-training schedule and perform pelvic muscle exercises. The postoperative care of patients having continent urinary diversions varies widely with the surgical techniques used and it is important to learn the surgeon's preferred routine or health care facility's procedures before caring for these patients.

Dimensions of pain: Sociocultural

Include demographics, support systems, social roles, and culture Age, gender, and education influence beliefs and coping strategies Must be assessed without stereotyping Families and caregivers influence the patient's response to pain through their beliefs and behaviors. For example, families may discourage the patient from taking opioids because they fear the patient will become addicted.

PROVIDING HOME AND FOLLOWUP CARE AFTER Extracorporeal Shock Wave Lithotripsy (ESWL)

Instruct patient to increase fluid intake to assist passage of stone fragments (may take 6 weeks to several months after procedure). Instruct patient about signs and symptoms of complications: fever, decreasing urinary output, and pain. Inform patient that hematuria is anticipated but should subside in 24 hours. Give appropriate dietary instructions based on composition of stones. Encourage regimen to avoid further stone formation; advise patient to adhere to prescribed diet. Teach patient to take sufficient fluids in the evening to prevent urine from becoming too concentrated at night.

NANDA

Many common NANDA diagnoses in Lower Bowel wellness & dysfunction: Nutritional deficiency Risk of infection; Alterations in protective mechanisms Constipation; Pseudo-constipation; Colic constipation Diarrhea; Fecal incontinence; Violation and risk of the integrity to skin Decreased tissue perfusion: gastrointestinal Fluid volume deficit; risk of fluid volume deficit Disruption of performance of the role; ineffective individual coping strategies ; difficulty to stay healthy; Disability to eat Knowledge deficit; Non-observance Risk of injury in perioperative; Disturbance in body image Acute pain; Chronic pain Body image disturbance

Risk factors for development of renal calculi

Metabolic: Increased urine levels of calcium, oxaluric acid, uric acid, citric acid Climate: Warm climates cause increase fluid loss, low urine volume, and increased solute conc. in urine Diet: Proteins that increase uric acid excretion Excessive amounts of tea or fruit juices that elevate urinary oxalate level Large intake of calcium and oxalate Low fluid intake Genetic Factors: Family history of stone formation, cystinuria, gout, renal acidosis Lifestyle: Sedentary occupation, immobility

Enuresis

Nocturnal enuresis (NE) is defined as voiding at night while asleep in a child over the age of five who does not have other urinary symptoms or disorders affecting the urinary tract. Bedwetting in children with daytime symptoms is usually caused by detrussor instability and dysfunctional voiding. Psychological problems are often present in this group, and constipation or soiling may coexist.

Assment

Physical assessment Mouth, abdomen, and rectum Laboratory tests Fecal specimens Diagnostic examinations Direct visualization Indirect visualization Bowel preparation

Nursing Interventions of BPH

Preoperative and postoperative nursing interventions for a patient with BPH are as follows: Reduce anxiety. The nurse should familiarize the patient with the preoperative and postoperative routines and initiate measures to reduce anxiety. Relieve discomfort. Bed rest and analgesics are prescribed if a patient experiences discomfort. Provide instruction. Before the surgery, the nurse reviews with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems. Maintain fluid balance. Fluid balance should be restored to normal.

implementation: Removal of indwelling catheters Alternatives to catheterization Suprapubic catheters External catheters

Prompt removal of an indwelling catheter after no longer needed is a key intervention that has proven to decrease the incidence and prevalence of HAUTI (hospital-acquired urinary tract infections) and is one of the "never events" identified by the Centers for Medicare and Medicaid Services (CMS). All patients should have their voiding monitored after catheter removal for at least 24 to 48 hours by using a voiding record or bladder diary. The bladder diary should record the time and amount of each voiding, including any incontinence. A bladder scanner can be used to monitor bladder functioning by measuring postvoid residual. [Review Box 46-11, Procedural Guideline: Using a Bladder Scanner to Measure Postvoid Residual), with students.] The first few times a patient voids after catheter removal may be accompanied by some discomfort, but continued complaints of painful urination indicate possible infection. Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention. The risk of urinary tract infection increases with the use of an indwelling catheter. Symptoms of infection can develop two to three or more days after catheter removal. Patients need to be informed of the risk for infection, prevention measures, and signs and symptoms that need to be reported to the nurse and health care provider. To avoid the risks associated with urethral catheters, two alternative are available for urinary drainage. A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The external catheter, also called a condom catheter or penile sheath, is a soft, pliable condom-like sheath that fits over the penis providing a safe and noninvasive way to contain urine. For men who cannot be fitted for a condom-type external catheter there are other externally applied catheters. One type attaches to the glans penis using hydrocolloid strips staying in place for multiple days and allows intermittent/straight catheterization. Another option available is a reusable condom like device that is held in place by specially designed underwear. [Review Box 46-12, Procedural Guideline: Applying a Condom Catheter, with students.] [Shown is Figure 46-15: A, Placement of suprapubic catheter above the symphysis pubis B, suprapubic catheter without a dressing.]

Implementation

Routine Colorectal cancer Promotion of normal defecation Sitting position Privacy Positioning on bedpan Successful nursing interventions improve the patients' and family members' understanding of bowel elimination. One of the most important habits to teach regarding bowel habits is to take time for defecation. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. When diagnosed early, colorectal cancer can be treated and eliminated. Following the guidelines for prevention and knowing the early symptoms and seeking medical help if these symptoms occur is the most effective way to prevent death from this disease. African Americans have the highest rates of cancer and highest death rates from cancer of any racial or ethnic group. There is a lower rate of colorectal cancer screening among African Americans but this disparity is decreasing. [Review Box 47-7, Screening for Colorectal Cancer, with students.] [Review Box 47-8, Cultural Aspects of Care: Variables Influencing Colorectal Cancer Screening in African Americans, with students.] A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort. Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Elevated seats require patients to use less effort to sit or stand. Patients restricted to bed use bedpans for defecation. Two types of bedpans are available. The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for patients with lower-extremity fractures, has a shallow upper end about 2.5 cm (1 inch) deep. The shallow end of the pan fits under the buttocks toward the sacrum; the deeper end, which has a handle, goes just under the upper thighs. The pan needs to be high enough so feces enter it. [Shown is Figure 47-9: Types of bedpans. From left, Regular bedpan and fracture bedpan.]

Nursing Diagnosis

Some diagnoses that apply to patients with elimination problems include: Disturbed body image Bowel incontinence Constipation Perceived constipation Risk for constipation Diarrhea Nausea Deficit knowledge (nutrition) The nursing assessment of the patient's bowel function reveals data that indicate an actual or potential elimination problem or a problem resulting from elimination alterations. In the examples discussed in the Nursing Care Plan in the textbook, a patient has constipation as a result of pain medications and decreased fiber intake. Associated problems, such as age, body-image changes, and skin breakdown require interventions unrelated to bowel function impairment. It is important to establish the correct "related to" factor for a diagnosis. This is depending on the thoroughness of your assessment and your recognition of the defining characteristics and factors that impair elimination. For example, with the diagnosis of constipation you distinguish between related factors of nutritional imbalance, exercise, medications, and emotional problems. Selection of the correct related factors for each diagnosis ensures that you will implement the appropriate nursing interventions. [Review Box 47-6, Constipation, with students.]

Medical Management of BPH

The goals of medical management of BPH are to improve the quality of life and treatment depends on the severity of symptoms. Catheterization. If a patient is admitted on an emergency basis because he is unable to void, he is immediately catheterized. Cystostomy. An incision into the bladder may be needed to provide urinary drainage.

Catheterization sizes

The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the catheter. Most adults with an indwelling catheter should use a size 14 to16 Fr to minimize trauma and risk for infection. Smaller sizes are needed for children such as a 5 to 6; Fr for infants, 8 to 10 Fr; for children, and 12 Fr for young girls. Indwelling catheters come in a variety of balloon sizes from 3 mL (for a child) to 30 mL for continuous bladder irrigation (CBI). The size of the balloon is usually printed on the catheter port. The recommended balloon size for an adult is a 10-mL balloon (the balloon is 5 mL and requires 10 mL to fill completely). [Shown is Figure 46-11: Size of catheter and balloon printed on catheter.]

Implementation: Medications Antimuscarinics: treat urgency, frequency, nocturia and urgency UI Bethanechol: treat urinary retention Tamsulosin and silodosin: relax smooth muscle Finasteride and dutasteride: shrink the prostate Antibiotics: treat urinary tract infections Be familiar with the medications and indications for all medications your patient is taking.

There are a small number of medications used to treat urgency, frequency, nocturia, and urgency UI. Antimuscarinics include darifenacin, oxybutynin, solifenacin, fesoterodine, tolterodine, and trospium and one that is not an antimuscarinic, mirabegron. The most common adverse effects of the antimuscarinics are dry mouth, constipation, and blurred vision. In some cases, these medications can cause a change in mental status in older adults. Urinary retention is sometimes treated with bethanechol, and men with outlet obstruction due to an enlarged prostate are treated with agents that relax the smooth muscle of the prostatic urethra, such as tamsulosin and silodosin, and agents that shrink the prostate, such as finasteride and dutasteride. You should be familiar with the medications and indications for all medications your patient is taking. When newly started on an antimuscarinic, you should monitor the patient for effectiveness watching for a decrease in symptoms such as urgency, frequency, and urgency UI episodes. A bladder diary is one of the best ways to do this. In addition, you should regularly assess the patient for side effects such as constipation by monitoring the bowel movement record. Watch for a decrease in bowel movement frequency, straining at bowel movements and changes in stool consistency. Urinary tract infections are treated with antibiotics. Patient with painful urination, are sometimes prescribed urinary analgesics that act on the urethral and bladder mucosa (e.g., phenazopyridine). Patients taking drugs with phenazopyridine need to be aware that their urine will be orange. They must drink large amounts of fluids to prevent toxicity from the sulfonamides and maintain optimal flow through the urinary system.

Assessment

Through the patient's eyes Nursing history What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. Identifying normal and abnormal patterns, habits, and the patient's perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient's problems.

Evaluation

Through the patient's eyes The patient or caregiver determines which therapies were the most effective Patient outcomes Develop a therapeutic relationship Evaluate a patient's level of knowledge Determine the extent to which the patient accomplishes normal defecation Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health

Treatment

Under-fives For the under-fives, explanation and advice about potty training is advised. Punishment should be avoided. Between five and seven years For children between five and seven years use star charts and rewards; encourage daytime fluids (avoid caffeine); treat constipation and daytime wetting before bedwetting. If the child is distressed and motivated towards treatment, manage as if over seven years old. Over-sevens For the over-sevens enuresis alarms (worn on the body or placed on the mattress) are most effective but require a motivated and determined child and parent. Desmopressin (10-40mg nasal spray or 200-400mg tablet) is rapidly effective but does not usually cure the underlying condition. It is good for short-term relief of wetting or where the use of an alarm is not possible or effective. There are few adverse effects. Imipramine may be effective, but the high incidence of adverse effects and the danger of overdose limit its usefulness. Oxybutinin may help the child with symptoms of bladder instability

Positioning bedpan

When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan. When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan by using the following steps: 1. Lower the head of the bed flat, and help the patient roll onto one side, backside toward the nurse. 2. Apply a small amount of powder to back and buttocks, or cover bedpan edge with tissue to prevent skin from sticking to the pan. 3. Place the bedpan firmly against the buttocks, down into the mattress, with the open rim toward the patient's feet. 4. Keeping one hand against the bedpan, place the other around the patient's fore hip. Ask the patient to roll back onto the pan, flat in the bed. Do not shove the pan under the patient. 5. With the patient positioned comfortably, raise the head of the bed 30 degrees. 6. Place a rolled towel or a small pillow under the lumbar curve of the patient's back for added comfort. 7. Raise the knee gatch or ask the patient to bend the knees to assume a squatting position. Do not raise the knee gatch if contraindicated. It is important to work with the client to decide what time is best for their routine and usual habits. Diapers and staying by while the client is on the toilet or bed pan do not promote dignity. The bedpan should be kept in the bathroom for sanitary purposes. [Shown is Figure Step 9 A-C from Box 47-9, Procedural Guidelines: Assisting Patient On and Off a Bedpan.]

Positioning on bedpan (Cont.) Prevent muscle strain and discomfort Elevate head of the bed 30 to 45 degrees Wear gloves when handling bedpans

When positioning a patient, it is important to prevent muscle strain and discomfort. Never try to lift a patient onto a bedpan. Never place a patient on a bedpan and then leave with the bed flat unless activity restrictions demand it. This forces the patient to hyperextend the back to lift the hips onto the pan. The proper position for the patient on a bedpan is with the head of the bed elevated 30 to 45 degrees. When patients are immobile or it is unsafe to allow them to raise their hips, it is safest for the caregiver and the patient to roll them onto the bedpan. Always wear gloves when handling a bedpan. [Review Box 47-9, Procedural Guidelines: Assisting Patient On and Off a Bedpan, with students.] [Shown at top is Figure 47-10: Improper positioning of patient on bedpan.] [Shown at bottom is Figure 47-11: Proper position reduces patient's back strain.]

Documentation Guidelines

e focus of the documentation in a patient with BPH includes: Degree of impairment. Client's description in response to pain. Acceptable level of pain. Prior medication use. Level of anxiety and precipitating/aggravating factors. Description of feelings. Awareness and ability to recognize and express feelings. Treatment plan. Teaching plan. Client's response to interventions, teaching, and actions performed. Attainment and progress toward desired outcomes. Modifications to plan of care. Referrals made.

Renal Calculi: Medical Management

Medical Management: Acute: treat pain, infection, obstruction Narcotics, for fluids—IV and po, strain urine Evaluate cause of stone formation: history, stone analysis Adequate hydration, dietary NA+ restriction, dietary changes, medication Treatment of struvite stones: control of infection

Nursing Process: Assessment

Through the patient's eyes Self-care ability Cultural considerations Health literacy Nursing history Pattern of urination Symptoms of urinary alterations

Elimination/Mobility Dysfunction (Constipation):Major Nursing Health Promotion and Wellness Teaching Opportunity

High Fiber diet. Consider dietician consult. Appropriate fluid intake daily for individual client. Which foods to avoid or use less of: fried, fatty, processed, rice, potatoes, cheese. Use of laxatives: Avoid using strong laxatives such as bisacodyl (Dulcolax, Correctol, Fleets, Carter's). Can mask undiagnosed bowel problem or make worse. Can cause severe cramping and pain over hours. Best options: Osmotic Cathartics [magnesium hydroxide; Sodium osmotic]. Rapid effect. Short term use no more than 3 days in a row. Careful options: Bulking agents such as psyllium seed, methylcellulose. Can cause bowel obstruction if not taken with lg. amt. of H2O.

Diagnosis for nocturnal enuresis

Bladder disease - detrussor instability, urinary tract infection (UTI), neurogenic bladder, posterior urethral valves. Polyuria - chronic renal failure and diabetes. Nervous system disorders - such as cerebral palsy and sedative medications.

Nursing Diagnosis

Nursing diagnoses common to 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

Surgical Management

Other treatment options include minimally invasive procedures and resection of the prostate gland. Transurethral microwave heat treatment. This therapy involves the application of heat to prostatic tissue. Transurethral needle ablation (TUNA). TUNA uses low-level radio frequencies delivered by thin needles placed in the prostate gland to produce localized heat that destroys prostate tissue while sparing other tissues. Transurethral resection of the prostate (TURP). TURP involves the surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra. Open prostatectomy. Open prostatectomy involves the surgical removal of the inner portion of the prostate via a suprapubic, retropubic, or perineal approach for large prostate glands.

Implementation: Acute Care

Acute care Catheterization Types of catheters

Assessment of Urine

Assessment of urine Intake and output Characteristics of urine Color Clarity Odor

Dimensions of pain: Cognitive

Beliefs, attitudes, memories, and meaning attributed to pain Influence response to pain and must be incorporated into the comprehensive treatment plan The meaning of pain to the patient can be particularly important. For example, a woman in labor may experience severe pain but can manage it without analgesics, because for her it is associated with a joyful event. The cognitive dimension also includes pain-related beliefs and the cognitive coping strategies that people use. For example, some people cope with pain by distracting themselves, whereas others convince themselves that the pain is permanent, untreatable, and overwhelming. Research has shown that people who believe that their pain is uncontrollable and overwhelming are more likely to have poorer clinical outcomes.

Urinary Elimination

Benign Prostatic Hypertrophy • Bladder Incontinence and Retention • Bowel Incontinence • Constipation/Impaction • Irritable Bowel Disease • Renal Calculi • Enuresis Urinary Incontinence and Retention

Act of urination

Brain structures influence bladder function. Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxation 1. Bladder wall stretching signals micturition center. 2. Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control. 3. When a person is ready to void, the central nervous system sends a message to the micturition centers, the external sphincter relaxes and the bladder empties.

Pain Mechanisms: Transduction

Conversion of a noxious mechanical, thermal, or chemical stimulus into a neuronal action potential Occurs at the nociceptors The noxious stimuli causes tissue damage, and the CNS converts the stimulus into an electrical signal called an action potential. Noxious stimuli cause release of a "biologic soup" of chemicals into the damaged tissues These substances activate nociceptors and lead to generation of an action potential carried to the spinal cord via A-delta fibers and C fibers Noxious (tissue-damaging) stimuli, including thermal (e.g., sunburn), mechanical (e.g., surgical incision), and chemical stimuli (e.g., toxic substances), cause the release of numerous chemicals such as hydrogen ions, substance P, and adenosine triphosphate (ATP) into the damaged tissues. Other chemicals are released from mast cells (e.g., serotonin, histamine, bradykinin, prostaglandins) and macrophages (e.g., cytokines). These chemicals activate nociceptors, which are specialized receptors or free nerve endings that respond to painful stimuli. Activation of nociceptors results in an action potential that is carried from the nociceptors to the spinal cord primarily via small, rapidly conducting, myelinated A-delta fibers and slowly conducting, unmyelinated C fibers. Inflammation lowers nociceptor threshold and increases the likelihood of transduction Peripheral sensitization Nociceptive pain In addition to stimulating nociceptors to fire, inflammation and the subsequent release of chemical mediators lower nociceptor thresholds. As a result, nociceptors may fire in response to stimuli that previously were insufficient to elicit a response. They may also fire in response to non-noxious stimuli, such as light touch. This increased susceptibility to nociceptor activation is called peripheral sensitization. For example, a sunburn with inflammation secondary to thermal injury can result in the sensation of pain or discomfort when the affected skin is lightly touched. The pain produced from activation of peripheral nociceptors is called nociceptive pain.

Renal Calculi Removal: Endourological Procedures

Cystoscopy - remove stones from bladder Cystolitholapaxy - cysto with lithotrite (stone crusher) - then flushed out of bladder Cystoscopic lithotripsy - cysto with pulverize stones Flexible ureteroscopes: remove stones from ureter, kidney pelvis - may be used with ultrasound, electrohydraulic, or laser lithotripsy Percutaneous nephrolithotomy -- nephrostomy tube left in place for a period of time

Elimination

Elimination refers to the secretion and excretion of body wastes both urinary and gastrointestinal. The nurse plays an important role in establishing and maintaining proper elimination patterns while caring for clients.

Bowel Elimination

Elimination- Elimination refers to the secretion and excretion of body wastes both urinary and gastrointestinal. The nurse plays an important role in establishing and maintaining proper elimination patterns while caring for clients. Bowel Elimination: • Bowel Incontinence • Constipation/Impaction • Irritable Bowel Disease

Monitoring and managing complications

Encourage increased fluid intake and ambulation. Begin IV fluids if patient cannot take adequate oral fluids. Monitor total urine output and patterns of voiding. Encourage ambulation as a means of moving the stone through the urinary tract. Strain urine through gauze. Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for clinging stones. Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and pain. Instruct patient to report any increase in pain. Monitor vital signs for early indications of infection; infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone.

Instruct patients who self-administer enemas to use the side-lying position. If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate.

Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient's priorities of care and preferences and use the best evidence when making decisions about your patient's care. When performing the skills in this chapter, remember the following points to ensure safe, individualized, patient care: Instruct patients who self-administer enemas to use the side-lying position. Tell them not to self-administer an enema while sitting on the toilet because this position results in the rectal tubing, causing friction that could injure the rectal wall. If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate, which increases the patient's risk of fainting while on the bedpan, bedside commode, or toilet.

Interview Caveats

Everyone has different bowel habits: what is different? Aging causes decreased mucus production and decreased muscle mass, but constipation is not normal. Review home meds...including OTC meds. Medications are #1 cause of abnormal bowel symptoms. Review client's usual diet...poor dietary intake #2 cause of abnormal bowel symptoms. Food dyes (think Pepto Bismol)...can turn stool red

Evaluation

Expected Patient Outcomes Reports relief of pain States increased knowledge of healthseeking behaviors to prevent recurrence Experiences no complications

Dimension of pain: Psyiologic

Genetic, anatomic, and physical determinants Influence how stimuli are recognized and described

Planning

Goals and outcomes Incorporate elimination habits or routines Reinforce routines that promote health Consider preexisting concerns Setting priorities Patients often have multiple diagnoses Teamwork and collaboration

Planning

Goals and outcomes Set realistic and individualized goals along with relevant outcomes Collaborate with the patient Setting priorities Patient's immediate physical and safety needs Patient expectations and readiness to perform some self-care activities Teamwork and collaboration

Factors Influencing Urination

Growth and development Sociocultural factors Psychological factors Personal habits Fluid intake Pathological conditions Surgical procedures Medications Diagnostic Examinations

Implemenation

Health promotion Patient education Promoting normal micturition Maintaining elimination habits Maintaining adequate fluid intake Promoting complete bladder emptying Preventing infection

Renal Calculi Removal

Indications for Endourologic, lithotripsy or open surgical stone removal: Stones too large for spontaneous passage Stones associated with bacteriuria or symptomatic infection Stones causing impaired renal function Stones causing persistent pain, nausea, or ileus Inability of patient to be treated medically Patient with one kidney

Referral Indications

Indications for referral to a specialist include: for evaluation and treatment in a community-based enuresis clinic; when there are indicators of urinary tract disease; on treatment failure; and where there are behavioral or psychological problems, with possible referral to community pediatrics or child mental health.

Planning and Goals

Major goals may include relief of pain and discomfort, prevention of recurrence of renal stones, and absence of complications.

Clinical Manifestations

Manifestations depend on the presence of obstruction, infection, and edema. Symptoms range from mild to excruciating pain and discomfort. Stones in Renal Pelvis Intense, deep ache in costovertebral region Hematuria and pyuria Pain that radiates anteriorly and downward toward bladder in female and toward testes in male Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic) Abdominal discomfort, diarrhea

Dimensions of pain: Behavioral

Observable actions used to express or control pain Facial expressions Socially withdrawn Less physically active Using relaxation Taking medication

Discharge Goals

Pain relieved/controlled. fluid/electrolyte balance maintained. Complications prevented/minimized. Disease process/prognosis and therapeutic regimen understood. Plan in place to meet needs after discharge.

6 ft long, wide segmented, muscular organ Parts: Mesenteric artery Para sympathetic & Sympathetic innervation Smaller role in H2O reabsorption & nutrient extraction than small intestine Stores wastes Eliminates byproducts: dead RBCs, glucose, remaining undigested food Helps maintain water balance Absorbs vitamins and some electrolytes Releases hormones that influence food movement, hunger, fullness, and feelings of well-being >500 species of bacteria ferment undigested food stuffs +break down fiber fatty acids colon food source + help make Vitamins: B1, B2,B12, (biotin, thiamine, riboflavin), K

SLIDE 90 ELIMINATION

Successful critical thinking requires synthesis of Knowledge Experience Information gathered from patients Critical thinking attitudes Intellectual and professional standards

Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate collect necessary information, analyze the data, and make decisions regarding your patient's care. During assessment consider all elements that build toward making an appropriate nursing diagnosis. Take into consideration the knowledge you have learned about the urinary system. Integrate the knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the process of urinary elimination and the impact on a patient and family. Reflect upon previous and personal experiences to help you determine a patient's elimination needs. Your experience with a UTI helps you to understand the frustration and embarrassment felt by the patient caused by frequency, urgency, and dysuria. Caring for other older adults with functional disabilities helps you to anticipate patient needs related to toileting. In addition, use critical thinking attitudes such as perseverance to find a plan of care to provide successful management of urinary elimination problems. A bladder-retraining program includes initiating a toileting schedule on awakening, at least every 2 hours during the day and evening, before going to bed, and every 4 hours at night. Negative reinforcement is not beneficial and promotion of caffeine containing foods & or drinks can contribute to episodes of incontinence. Professional standards provide valuable directions for management. You are in a key position to serve as a patient advocate by suggesting noninvasive alternatives to catheterization use (e.g., the use of a bladder scanner to evaluate urine volume without invasive instrumentation or implementation of a voiding schedule for the incontinent patient). Standards and guidelines prepared by nursing specialty organizations as well as those developed by national and international professional organizations are valuable tools to use when critically evaluating patient problems and developing a plan of care. The professional nurse will incorporate such evidenced based guidelines into the plan of care. There are two nursing organizations, the Society for Urological Nurses and Associates (http://www.suna.org) and the Wound, Ostomy, Continence Nurses Society (http://www.wocn.org) that offer many resources related to continence care. Both organizations have specialty certification agencies offering entry level and advanced practice specialty certification. [Review Box 46-3: Resources for Urology/Continence Nurses] A urinary drainage bag should be emptied at least every 8hr; cleansing a cath should be performed down and away from the catheter and perineum; sterile technique is used to collect a urine specimen from a closed drainage system; and the drainage bag should NEVER be above the client's bladder

Cause of BPH

The cause of BPH is not well understood, but testicular androgens have been implicated. Elevated estrogen levels. BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive. Smoking. Smoking increases the risk of acquiring BPH. Reduced activity level. A sedentary lifestyle could also lead to the development of BPH. Western diet. A diet high in animal fat and protein and refined carbohydrates while low in fiber predisposes a man to BPH.

Discharge and home care guidelines

The patient and the family require instructions about how to promote recovery. Instructions. The nurse provides written and oral instructions about the need to monitor urinary output and strategies to prevent complications. Urinary control. The nurse should teach the patient exercises to regain urinary control. Avoid Valsalva maneuver. The patient should avoid activities that produce Valsalva maneuver like straining and heavy lifting. Avoid bladder discomfort. The patient should be taught to avoid spicy foods, alcohol, and coffee. Increase fluids. The nurse should instruct the patient to drink enough fluids.

Pain Mechanism Transduction cont.

Therapies that alter local environment or sensitivity of peripheral nociceptors Prevent transduction and initiation of an action potential NSAIDS Decreasing the effects of chemicals released at the periphery is the basis of several drug approaches to pain relief. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen and naproxen, exert their analgesic effects by blocking the action of COX

Diagnosis of BPH

There are several ways to diagnose benign prostatic hypertrophy. Digital rectal examination (DRE). A DRE often reveals a large, rubbery, and nontender prostate gland. Prostate specific antigen levels. A PSA level is obtained if the patient has at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management. Urinalysis: Color: Yellow, dark brown, dark or bright red (bloody); appearance may be cloudy. pH 7 or greater (suggests infection); bacteria, WBCs, RBCs may be present microscopically. Urine culture: May reveal Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas, or Escherichia coli.

Pain

a complex, multidimensional experience that can cause suffering and decreased quality of life One major reason people seek health care To effectively assess and manage patients with pain, you need to understand the physiologic and psychosocial dimensions of pain.

Pathophysiology: kidney stones

presence of stones anywhere in the urinary tract Most commonly found in the renal pelvis and calyces Stones forming in the kidney —nephrolithiasis Stones formed in the ureters —ureterolithiasis May be single or multiple calculi, ranging in size from a grain of salt to the size of a pebble or staghorn calculus Composition of calculi Formed of mineral deposits—predominantly calcium oxalate and calcium phosphate Uric acid, struvite, and cystine are also calculus formers The renal calyces are chambers of the kidney through which urine passes. The minor calyces surround the apex of therenal pyramids.