urinary and bowel

All about pee

1.2- 1.5 Liters per day output (____ cc/hour) Light yellow to dark amber Transparent Faintly, aromatic (food and drugs alter odor and color) pH 4.5 to 8 Urea/uric acid (waste products of protein and amino acid metabolism) In adults, the average amount of urine per void is approximately 250 - 400 ml. All but 5 - 10 ml of urine is typically emptied from the bladder. Urine output can vary greatly depending on intake and fluid loss. Patients with a catheter should drain a minimum of 30 ml of urine per hour. Urine output less than 30 mL/hr may indicate inadequate blood flow to the kidneys. The color of urine ranges from light yellow to a darker yellow to a dark brown-yellow called amber. Hydration status affects urine color. High fluid intake may result in almost colorless urine. Dark amber or orange-brown urine would likely be caused by decreased fluid intake. Medications can also alter urine color. Urine is normally transparent. Freshly voided urine should appear clear and without sediment (what is sediment??) Urine draining from an indwelling catheter should appear clear and without sediment in the tubing but it may occasionally have mucus shreds. Why do you want to monitor the urine from a catheter from the tubing NOT the bag? Urine that has been sitting may appear cloudy or have sediment and should not be used to describe current urine status. The odor of freshly voided urine is typically described as aromatic. Generally, the more dilute the urine the fainter the odor. The more concentrated the urine the stronger the odor. Urine that has been sitting for a period of time may smell like ammonia. A strong offensive odor is not normally present in urine that is free from infection. Lighter colore with more fluids Specific gravity varies depending on fluid intake and quantity of solutes; concentrated urine has higher specific gravity Lower specific gravity = more dilute the urine is; a higher speicific gravity means the urine is more concentrated.

Bowel Diversions - Ostomies

: Certain disease /conditions prevent normal passage of stool; temporary or permanent artificial opening in the abd wall; location determines consistency of stool

Loop colostomy

: Usually done emergently; temporary; usually involves transverse colon; two openings through one stoma - stool and mucus; external supporting device usually removed in 7-10 days

Motility

movement through the tract: two types Peristalsis - propels contents along the entire length of the small and large intestine Segmentation: involves alternating contraction and relaxation - slowing the passage of intestinal contents to allow more absorption and digestion Absorption - partially digested food (chyme) empties from the stomach

Nursing Interventions for Clients with Indwelling Catheters

Encourage large amounts of fluid intake Intake of foods that create acidic urine Perineal care Change catheter and drainage system only when necessary Catheterize only when necessary Maintain sterile closed-drainage system Follow good hand hygiene Prevent fecal contamination REMOVE CATHETER AS SOON AS POSSIBLE

Ongoing Assessments of Clients with Indwelling Catheters

Ensure tubing free of obstructions Ensure tubing not clogged Ensure there is no tension on catheter or tubing Ensure gravity drainage maintained Ensure no loops in tubing below entry Keep drainage receptacle below level of client's bladder Ensure closed drainage system Observe flow of urine q. 2 to 3 hours Note color, odor, abnormal constituents If sediment present, check more frequently

Nursing Considerations:

Ensuring accurate placement Maintaining suction Monitoring intake and output Providing nasal and oral care Administering medications

Catheters and Urinary Diversion Interventions

External (condom) Intermittent Indwelling Suprapubic Nephrostomy tubes

female vs male urinary tract

From the bladder the urine goes through the urethra Males and females are different. Urethra extends from bladder to urinary meatus. Male urethra is 20 cm. or 8" long and serves as a passageway for urine and semen. Meatus is located at the distal end of the penis. Urethra has a mucous membrane lining that is continuous with the bladder and ureters. An infection of the urethra can extend thru the urinary tract to the kidneys. Urethra is 4 cm. or 1.5" long and is directly behind the symphysis pubis and anterior to the vagina in women. Women are particularly prone to urinary tract infections because of their short urethra and proximity to the vagina and anus

Outcome Criteria

Goals may include: The client will: Demonstrate a normal pattern of bowel elimination without evidence of constipation, diarrhea, fecal incontinence, or distention Remain free of preventable complications or adverse consequences from altered bowel elimination

Implementation

Health Promotion Teaching Diet Fluids Activity and exercise Bowel habits Colorectal screening

Ostomy Stool Characteristics

Ileostomy - liquid fecal drainage, unregulated, digestive enzymes (damaging to skin), minimal odor Ascending colostomy - liquid drainage, unregulated, digestive enzymes, + odor Transverse colostomy - mushy drainage, + odor, no control Descending colostomy - more solid, may be regulated.

Nursing Diagnosis

Impaired Urinary Elimination Readiness for Enhanced Urinary Elimination Functional Urinary Incontinence Overflow Urinary Incontinence Reflex Urinary Incontinence Stress Urinary Incontinence Urge Urinary Incontinence Risk for Urge Urinary Incontinence Urinary Retention

Urinary Incontinence

Incontinence - involuntary loss of urine from bladder. Functional: normal bladder and spincter control but person cannot reach toilet because of environmental, physical, or cognitive barriers . Reflex: involuntary loss of urine at predictable intervals (e.g. when a certain amount of urine is in the bladder) seen in dysfunction in CNS from Parkinson's, CVA, SCI, MS Stress: involuntary loss of less than 50 mL of urine associated with activity that increases abdominal pressure; more common in women but occurs in men who have had prostatectomy and radiation; coughing, sneezing, laughing, lifting jumping running (cause = weak pelvic floor muscles, childbirth, obesity...) Urge: involuntary loss of urine occurring after feeling an urgent need to void. Sometimes overlaps with overactive bladder syndrome - muscles overactive and cause sudden urge to void. Urge UI is most common type of UI in older adults. Can't quite tell the bladder is full then when you sense it it is sudden. Seen in pt w uti's, those on diuretics, smokers, with etoh use. Total: - continuous, unpredictable loss - if type of incontinence doesn't fit the other categories Look at table 32.2

Fecal/Bowel Incontinence

Incontinence inability to control fecal discharge thru anal sphincter; usually associated with impaired functioning of anal spincter or its nerve supply. Prevalence increases with age. Can lead to social isolation.

patho affecting voiding

Infections: - most common UIT are infections of the urethra (urethritis) or bladder (cystitis) called lower UTI's. Upper UTI if infection of ureter or kidney pelvis or tubule system. Men less susceptible re longer urethra. CAUTI = cath assoc infection - if cath is in greater than 2 days. preventable so hosp don't get paid Increased risk of UTI if: Wipe back to front Sex SS - urgency, pyuria (pus), hematuria, in elderly confusion Hypotension - if not enough blood - body wants to keep urine when BP is too low, rental arteries don't have enough pressure to cause glomerulo filtration. Watch urine output!!! Muscle tone - weakened abd muscles or perineal muscles can impair bladder contraction; if someone has a cystocele - (protrusion of the bladder into vaginal canal) - will have patient with increased dribbling and inability to empty bladder completely. occurs when the supportive tissue between a woman's bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina - can happen with childbirth. If have catheter = get decreased tone Pregnancy: pressure on bladder, may not empty bladder completely so more prone to UTIs Surgery - need post op patients to void within 8 hours...anesthesia slows GFR reducing urinary output. Meds affect urination - diuretics increase urinary production by preventing reabsorption of water and electrolytes from the tubules back into the bloodstream; pyridium makes it orange

Risk Factors For Diarrhea

Intestinal disease Intestinal toxins/infections Medications-antibiotics, antacids Laxative abuse Lifestyle changes that cause stress & anxiety Traveling-out of the country Specific food allergy

Renal and Urinary Systems

Kidneys Ureters Bladder Urethra Function to maintain the body's state of homeostasis by regulating fluid and electrolyes, removing waste, and providing hormones involved in RBC production, bone metabolism, and control of blood pressure.

Planning

Maintain or restore a normal voiding pattern Regain normal urine output Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem Perform toilet activities independently with or without assistive devices Contain urine with the appropriate device, catheter, ostomy appliance, or absorbent product

Intestinal Obstructions

Mechanical Causes Hernia Intussusception Torsion Diverticulosis Tumor Functional Causes Paralytic ileus = Adynamic ileus Post-op abdominal surgery Hypokalemia Spinal cord injury Inflammatory conditions

Nursing Interventions for Altered Bowel Function

Medication Use Laxatives - Table 33-4 Antidiarrheal Agents - Table 32-5 Antiflatulence Agents Enemas Small-Volume Large-Volume Return-Flow Rectal Tubes Cathartics/laxatives - drugs that induce emptying of the intest. Habitual use of laxatives lead to constipation and irreg. frequency.Prep for procedures Cathartics have stronger effects. Enemas- solution introduced into the lg. Intest. For the purpose of removing feces. Suppositories - bullet shaped substance inserted into the rectum beyond the anal sphincter where it melts to aid in elimination. Digital removal- with prolonged retention of feces, fecal impaction occurs preventing passage of normal stool. Liquid fecal seepage around hard stool can occur. Oil retention enema is given prior to digital removal to soften stool. Cleansing- given to clean out the bowel for relief of constipation, fecal impaction, bowel prep prior to dx tests or surgery or bowel training. Enemas till clear -clear of feces fluid may still be slightly colored (3 is the limit). Retention -retained in the bowel for a prolonged period of time (lubricate stool, administer meds, (30min.) Return Flow- (Harris Flush) - used to expel flatus. Fill bag with 400 cc water, instill 100-2000cc using siphon process raise and lower bag to expel gas.

Factors That Influence Bowel Elimination pt 2

Medications- antibiotics can cause diarrhea, opiates (narcotics)constipation, laxatives stimulate, antidiarrheals; asa meds result in red/or black stool (re bleeding), iron leads to black stools re: oxidation of the iron, abx cause grey/green stools, antacids cause whitish or white specs. Health status- tumors, infection of intestines, spinal cord injury Stress - anxiety/anger-diarrhea, worry/depressed-constipation Dx test- bowel cleansing alters elimin.pattern Surgery & anesthesia- direct handling of bowels and slowing of peristalsis alter bowel elimination. After surgery it takes 3 days for normal bowel function to occur. Post op: narcotics may lead to constipation Pain - eg hemorrhoid pt will suppress urge to deficate and get constipated.

Altered Urine Elimination patterns

Most adults can postpone emptying bladder until it has 250 - 400 cc urine Frequency: voiding greater than 4 -6x/day increased fluid intake, UTI, stress, Pregnancy; usually less than 250 cc/urine Nocturia: voiding 2x or more at night Urgency: strong desire to void, despite amount of urine in bladder caused by psychological stress, UTI, weak perineal muscle control, incompetent spincter, Enuresis: peeing in bed Hematuria - gross = visible; occult = not visible to the naked eye. Pyuria - pus Urinary Retention can't empty bladder... may get up to 2-3L urine; you can feel it if it's bigger than 600-700 cc.

Functions of the GI Tract

Motility: Absorption: Defecation: stomach will store food for about 4 - 5 hours usually

Structure of the GI System

Mouth, esophagus, stpomach, SI, LI, Rectum, Anal canal and anus. The small intestines are the longest part of the G.I tract and this is where 90% of digestion takes places. The wall of the duodenum secretes mucus to neutralize acids that occur from the stomach. The digestive juices excreted from the liver and pancreas also enter into the duodenum. Large intestines are where the re-absorption of water, vitamins and minerals occur, they also secretes mucus to aid in movement of feces. Large Intestine is the lower portion of the alimentary tract. Function: water absorption, formation and expulsion of feces. Ileocecal valve is the barrier between the sm. intestine & the lg. intest. Chyme : waste products of digestion received by the lg. Intse. Composed of liquid, watery state as it passes thru lg. intest. water is absorbed.800-1000cc/day.

Color

Normal color is brown infants yellow, adults brown due to bile pigmentation. In absence of bile stool may be white (clay colored). Diet can effect color blackish if high red meat intake.Blackish stools (Tarry)could be from upper GI bleeding while (frank red)blood is lower GI bleeding. Greenish color if dk. green veg.eaten.

Nursing Dx R/T Bowel Elimination

Nursing Dx Potential for constipation related to side effects of medication as evidenced by patient's verbalization I feel blocked up..I haven't gone in 4 days..... I usually go every morning after my coffee.. Bowel Incontinence related to loss of anal sphincter control as evidenced by inability to control bowels, 2 episodes of "accidents" every shift, pt. States" I feel like a baby and I don't want to wear diapers" PAIn Diarrhea Impaired skin integrity FVD Constipation Perceived Constipation Risk for Constipation Diarrhea Bowel Incontinence

Odor

Odor is due to the bact action of break down of digested foods. Aroma effected by foods digested, blood, pus, or bact. in stool. - should be aromatic, pungent

Assessing Elimination Status

Pattern -How often, when Changes- blood, mucus Aids - laxatives enemas Problems - food related, meds, physical, emotional, Artificial orifices, hemorrhoids (abnormally distended veins)..colostomy

implementation: lifestyle modifications

Regulating fluid intake Smoking cessation Weight loss Preventing constipation Lifestyle modifications include regulating fluid intake, smoking cessation, losing weight, and establishing a good bowel regimen to prevent constipation. Sufficient water intake is important for the success of bladder training programs. Weight reduction is especially helpful for patients with stress incontinence.

Urinary Elimination May Become the Etiology

Risk for Infection Situational Low Self-Esteem Risk for Impaired Skin Integrity Toileting Self-Care Deficit Risk for Deficient Fluid Volume or Excess Fluid Volume Disturbed Body Image Deficient Knowledge Risk for Caregiver Role Strain Risk for Social Isolation

Stool Specimen Collection

Routine- FOBT - occult = hidden; heme = blood Put stool on card, add chemical developer, if blue = blood Looks for bleeding in GI tract (e.g from tumors or intestine) if bleeding is on the surface of the stool it is likely from hemorrhoids and NOT occult. Used in colorectal exam screening. Be mindful that some false positives from red meat, iron preps, asa, steroids, NSAIDs, high doses of Vit C Culture:: PPE...place in container...pt. Can obtain themselves...use bedpan /don't place toilet tissue in bedpan....place in labeled container..transport in plastic bag with required lab slip on outside. O & P lab sends up test tubes use applicator to place stool specimen in test tubes... Radiologic - x ray. Usually pt has to swallow barium which will show up as white (may cause constipation after) Sigmoidoscopy - looks at rectum and colon Colonscopy - goes beyond the colon to the ileoceal valve. (more painful) Think about what you need to do for these procedures e.g. for which procedures patient will need to be NPO;

Interventions to Promote Elimination

Routine- Establish reg pattern of elimination at reg times. Pt. needs 10-15 min. (uninterrupted time). If urge to defecate is constantly ignored the defecation reflex will be lost, causing feces to remain longer in intest., increased water absorption, making feces hard and difficult to pass. Use communication skills to discuss bowel patterns. Positioning- comfortable position needed. Squatting position common. Assess need for elevated toilet, commode, Privacy- considered a very private act. Use BR if possible, pull drapes close doors. Comfort- provide quiet, comfortable as possible place. Activity- needed to promote GI activity and maintain reg. frequency.Teaching related to inactivity and constipation. Exercises for immobile client. Exercises to strengthen abd. and perineal muscles used for defecation.T & P ROM Diet/Fluids - High fiber foods, 2000cc fluids/day

Evaluation

Sample Goal: Client will demonstrate normal pattern of bowel elimination without evidence of constipation, diarrhea, fecal incontinence, or abdominal distention. Sample Outcome: Client experiences a bowel movement within 24 hours and then every day during rehabilitation. Use previously developed goals and outcomes to evaluate client responses to nursing interventions.

assessing urine pt 2

Specific gravity is the weight or concentration of urine as compared to water. A low specific gravity is usually caused by over hydration or pathologic conditions that affect the kidneys ability to concentrate urine. A high specific gravity occurs because of fluid volume deficits. Reagent strips (urine dipsticks) are used to measure the amount of certain substances in the urine. They can test for glucose, proteins or ketones in the urine. The strips can also be used to measure pH or the presence of occult blood. The results are quick and can provide the physician and nurse with rapid assessment data. A urinalysis most common screening tests. It provides information on color, turbidity, pH, and specific gravity. Indicates the presence of protein, glucose, ketones, blood cells , bacteria and casts. The collection can be done any time of day but the first void of the morning is preferred if possible. Table 32-3 on page 1028 has a good description of the urinalysis results. Urine culture and senstivity - determine what microorganisms are causing a UTI and what antibiotics can be used to treat the UTI. After the microorganisms are grown, the lab will test which antibiotics will inhibit its growth. If an antibiotic inhibits bacterial growth, the bacteria is said to be sensitive to the antibiotic. If the antibiotic does not inhibit bacterial growth the organism is considered resistant.  . Blood tests can be analyzed to screen for kidney disease. BUN measures the amount of urea nitrogen in the blood. When kidneys are diseased they are unable to excrete urea adequately and the urea begins to accumulate in the blood causing the BUN to rise. Normal = 8 - 25 mg/100mL according to text. Other factors can also elevate the BUN such as high dietary protein intake, fluid deficit, infection and gout. Because of this BUN is not a highly sensitive indicator of impaired renal function. Serum creatinine is a more sensitive indicator of renal function. Creatinine is the waste product formed from the breakdown of skeletal muscle tissue. Diet and other factors do not impact creatinine. An elevated serum creatinine concentration is indicative of impaired renal function. Normal = 0.6-1.2 GFR - how much plasma filtered through glomeruli per unit of time. Need to know pt's age, gendter, race, and serum creat. If less than 60 = kidney disease & need to adjust meds

urine formation

The nephrons of the kidney are composed of six parts: the glomerulus, Bowman's capsule, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct. Each kidney contains 1 million nephrons. Each nephron has a glomerulus, a tuft of capillaries surrounded by Bowman's capsule. The plasma proteins and blood cells move easily from the glomerulus into the capsule. From the capsule the filtrate moves to the tubule. Proximal convoluted tubule Most of water and electrolytes are reabsorbed Loop of Henle Solutes such as glucose reabsorbed here Other substances secreted Distal convoluted tubule Additional water and sodium reabsorbed here under control of hormones (ADH) Controlled reabsorption in the distal convoluted tubule allows fine regulation of fluid and electrolyte balance in the body Formed urine then moves to: Calyces of the renal pelvis Ureters Bladder

catheter irrigation

The purpose of irrigation is to cleanse the lumen of the catheter to promote more patency of the tube. Solution is instilled through the tube directly into the bladder. It can be dome to remove blood clots or mucous or apply medication to the bladder wall. When irrigation is needed, it is recommended to use a closed method of irrigation when possible. See page 1039 in your text for pictures. When performing continuous bladder irrigation a 3 way indwelling urethral catheter must be in place. One lumen is the balloon to keep the catheter in place, the second lumen is used to allow urine to pass into the collection bag and the third lumen is to instill the irrigation solution. Three way irrigation is often used in patients with blood clots in their bladder.

Physical Assessment

This is a different sequence for assessing since palpation may disrupt bowel motility and peristalsis Inspection: Abdomen is normally convex and symmetric. Auscultation: Performed prior to percussion or palpation. Borborygmi = growling...; normally hear pretty fast. TRUST what you hear!!! - Paralytic ileas = paralyzed bowel = now BS Percussion: Used to identify air, fluid, or solid masses in the abdomen if abnormality is suspected. Palpation: Area thought to contain abnormalities is examined last. Measurement of abdominal girth: Usually compared over time; used in assessing ascites. Perirectal examination: Only used in selected patients

implementation: Scheduled Voiding Regimen

Timed voiding Prompted voiding Habit retraining Bladder training Scheduled voiding regimens is effective in decreasing incontinence. Timed voiding is the use of an unchanged, fixed toileting schedule. This is used most often for patients with cognitive or physical impairments. Prompted voiding involves the use of regular checks (usually every 2 hours) to determine if the patient perceives the need to void. Sometimes just asking the patient if they need to void triggers the urge to void. Habit retraining schedules voiding times in an attempt to approximate the patients usual voiding pattern. Helpful is patient has a predictable pattern of incontinence such as after meals or after diuretics. Bladder training starts with scheduled voiding. Patients void at scheduled times and suppress the need to void in between times. The time interval is gradually increased to 4 hours. Posting the voiding regimen is helpful for patients and caregivers. Success is based on consistency.

Bladder and Ureters

Ureters are 10-12" long and 0.5" in diameter. At the junction of ureters and bladder, there is a flap-like fold of mucous membrane which acts as a valve to prevent reflux (backflow) of urine back into the ureters

Urinary System Function

Urine formation Filtration Reabsorption Secretion Urine excretion Blood pressure regulation Main function of kidney is to regulate the volume and composition of the body's extracellular fluid - it does this by selectively keeping wanted water and other substances AND getting rid of unwanted water.

Characteristics of Stool

Volume Color Odor Consistency Shape Constituents

Evaluation

Were the client focused goals: Met Partially met Not met What do you need to do now?

Implementation: health promotion

What are we going to do to assist the patient in meeting their goals/outcomes? 8-10 glasses/d, adequate fluid intake flushes out microorganisms decreasing the risk of infection or obstruction. It also stretches the detrusor muscle to prevent atrophy (remember the bladder is a muscle!!) If the patient is incontinent, dilute urine is les irritating on the skin Avoid irritants such as caffeine and alcohol. Avoid constipation Weight management will decrease the intra-abdominal pressure and may decrease incontinence. UTI prevention: Urinate with 1st urge Wipe front to back Cotton undergarments Avoid tight fitting clothing Avoid diaphragm, spermacides if recurrent UTI Avoid bubble bath Educate patient about hand hygeine Teach signs and symptoms of UTI Pelvic floor exercises: loss of perineal and abdominal muscle tone can contribute to urinary retention and incontinence. Educate patient how to perform Kegel exercises.

Alterations in Bowel Function: Distention

accumulation of excessive amounts of flatus or liquid or solid contents patient complains of "fullness" & discomfort with the inability to pass flatus or stool. Primary cause: obstruction

Valsalva maneuver

additional muscles aid in the act of defecation, voluntary contraction of abd. muscles and diaphragm cause an increase in intraabd. pressure. "bearing down"

An external catheter

also called a condom catheter, can be used on male patients who are unable to control voiding. It is composed of a sheath, like a condom, and a tube connecting the device to a collection bad. An external catheter has a lower risk of infection when compared to an indwelling catheter. I have only seen these catheters used in rehab and long term care facilities.

Urodynamic studies

are used to detect abnormalities in bladder function or voiding.

After the removal

assess the patient's perineum and meatus for any signs of redness or irritation and provide perineal care. Make the patient aware that some dribbling is not uncommon after removing the catheter. Encourage fluid intake to distend the bladder. Voiding should be expected within 6 hours of the catheter removal. If the patient has not voided 8 hours after catheter removal assess for urinary retention with a bladder scanner is available. If the patient has difficulty reestablishing voluntary control of urination notify the physician. It may be necessary to insert another indwelling catheter or perform intermittent catheterization.

Double-barrel colostomy:

bowel is surgically severed and two ends brought out onto the abd; proximal stoma functions and distal stoma is nonfunctioning

Shape-

depends on condition of colon. Usually tubular (formed to the rectal canal), but varies. Obstructions may produce narrow pencil thin stools, increased time in the colon may produce marble-like stool

Defecation

emptying of lg. Intest. Bowel Movement. Stool, feces, BM.Should be at REGULAR INTERVALS- varies greatly among individuals.

Flatulence-

gas; sources of flatulence = action of bacteria on chime in the large intestine, swallowed air, and gas that diffuses between the bloodstream and the intestine. Most gas that is swallowed is let out by belching (eructation). But lg amounts of gas can result in gastric distention.

radiologic examination

include a KUB (flatplate of the abdomen to visualize the kidneys, ureters and bladder) and the intravenous pyelogram (IVP). The KUB is helpful for detecting malformations in the size or shape of the kidneys, ureters or bladder are also identify the presence of kidney stones that could obstruct urine flow. An IVP visualizes the urinary system with the use of radiopaque dye (contrast) injected intravenously. Films are taken at set intervals to visualize the flow of the dye through the kidneys, ureters, bladder before it is excreted. The patient has to be NPO after midnight for the procedure. Make sure to check for allergies to contrast dye or contrast media.

Intermittent catheterization

involves introducing and removing a catheter to permit drainage of urine at routine intervals. It may also be used to obtain a urine specimen. It is most often used in patients with spinal cord injuries or other neurologic impairment. The incidence of UTI is less with intermittent catheterization as compared to indwelling catheters.

Care of the indwelling catheter

is important to decrease the risk of UTI. The catheter, drainage collection tubing and bag represent a closed system and should not be disconnected except to change to a new closed system. Change the system if the catheter becomes clogged, obstructed or infected or is in place for 30 days. Empty the collection bag every 8 hours and as needed. The use of a catheter strap of tape will help prevent the catheter form pulling. The drainage collection bag should remain below the level of the bladder to maintain proper drainage and to prevent backflow. Cleanse the patient's perineal area and the catheter at least daily and after a bowel movement.

nephrostomy tube

is placed in the renal pelvis of the kidney to permit outflow of urine and to prevent backup of urine into the kidney. Record the output from each nephrostomy tube separately. NEVER clamp a nephrostomy tube because doing so would cause backup of urine that could lead to renal damage.

A suprapubic catheter

is placed into the patients urinary bladder through the abdomen just above the symphysis pubis. Suprapubic catheters are associated with a lower incidence of UTIs compared to indwelling catheters. Complications include obstruction of urine flow from the bladder from accumulation of sediment or clots in the bladder, and closing of the bladder wall over the catheter tip. The catheter also runs the risk of being kinked due to the small flexible tubing.

Cystoscopy

is the insertion of a tube into the bladder. The direct visualization allows the physician to look for abnormalities such as tumors or stones. Stones can be removed with specialized instruments. After the procedure watch for hematuria, urinary retention, dysuria or bladder spasms and signs and symptoms of a UTI.

Large Intestine

large intestine is from the ileocecal valve to the anus parts of the large intestine: ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anal canal involved in absorption of water, electrolytes, vitamins. Contains bacteria which serve a number of functions absorption of vitamins (B and K) produce small fatty acids used as energy by GI epithelial cells help breakdown indigestible molecules final water content of feces is about 200 ml

Alterations in Bowel Function: Diarrhea

liquid watery stools..deals with the consistency and frequency, can be protective if there are irritants in the intestional tact (diarrhea flushes it out). Concern is that it can cause serious fluid/electrolyte losses. C dif concern. Look over table for major causes of diarrhea.

Alteration in Bowel Elimination - Fecal Impaction

mass of hardened feces in rectum...recognized by seepage but no stool. Pt feels like he needs to defecate but can't and may have rectal pain. Pt may become anorexic, abdomen becomes distended and n/v may occur. Ususally trt with oil retention enema. accumulation of hardened feces in the rectum. generally the result of unrelieved or untreated constipation. suspected when there has been no BM for several days, followed by the seepage of liquid or semi-liquid stool. determined by hardened stool in the rectum or by digital exam done by a physician

Indwelling catheters

may be needed for the management of urinary retention when intermittent catheterization is not helping or for incontinent patients with pressure ulcers. Indications for catheterization include accurate monitoring of intake and output in critical patients, post-operative for 1-2 days during the acute recovery phase, they may be placed for comfort measures for terminally ill patient

End colostomy:

one stoma formed from the proximal end of the bowel and distal portion of the GI tract removed or sewn closed (Hartman's pouch); common in colorectal cancer and rectum is usually removed; temporary in surgery for diverticulitis

Absorption

partially digested food (chyme) empties from the stomach into small intestine where digestive process is completed and absorption of nutrients and fluids begins. Most absorption occurs in duodenum and jejunum. Final absorption in the large intestine. Amount of absorption depends on speed of movement through the colon - longer = more

Defecation

process begins when feces is moved by peristalsis into the rectum and causes rectal distention... this triggers the need for bowel evacuation. Called Defecation reflex

Consistency

soft, semisolid, formed, liquidly, hard. Influenced by diet/fluid intake, GI motility or malabsorption.

Defecation Reflex-

stimulated when the fecal mass stretches the rectum causing internal anal sphincter to relax and colon contracts ...the external sphincter must then voluntarily be relaxed =elimination occurs If the external sphincter isn't relaxed defecation will be delayed....delayed too often will lose the reflex entirely.

Volume

usually 75% water and 25% solid; once every day or every other day.... About 100 - 300 grams

Constituents

waste residue of digestion bile, secretions, bact, fat...abnormal constituents blood, helminths, parasites, mucus...

assessing a urine specimen

A random specimen is done when a sterile specimen is not needed. The urine should not be contaminated with feces or toilet paper but may be taken from a bedpan, urinal or hat in addition to voided into the specimen cup. A random specimen can be used for toxicology screens. A clean catch, or midstream specimen is used when a specimen relatively free of microorganisms is needed. The patient voids into a sterile specimen cup. Remember to instruct your patient on the proper cleaning needed before the specimen is collected. A 24 hour urine specimen is required for accurate measurement of kidney excretion of subtances such as protein, creatinine. Patient education is done by the nurse to ensure the specimen is collected correctly. If any of the urine is inadvertantly discarded the collection must start over as the missing urine may change the results. The collection is typically started in the morning after the first void. All urine is collected in a container (bedpan, hat, urinal) and placed in the collection container. The container must be refrigerated or kept on ice during the collection period. Obtaining a specimen from a catheter is done when either the patient cannot void or already has a catheter in place. The urine collected will be sterile if done correctly. If the patient is unable to void an "in and out" catheter may be placed. This is also known as a straight cath. A catheter is placed long enough to collect the specimen. A patient who already has a catheter can have a sterile specimen obtained. The urine is collected from the self sealing port on the tubing. Sterile specimens should NEVER be obtained from the collection bag...why??? The drainage bag is not sterile and has been opened to be emptied and has had urine sitting in it all of which promote bacteria growth!

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.

Assessment: Risk Identification

Adequacy of fiber and fluid intake Ignoring the urge to defecate Altered mobility Diagnostic procedures, surgery or anesthesia Fear of pain on defecation Chronic diseases and medications (especially opiates) Lifestyle changes

Factors That Influence Bowel Elimination

Age- elderly bowel conscious; motility slows with aging - frequenc decreases; weakened pelvic muscles may decrease frequency and result in constipation., infants pass many stools etc. Fluid/diet- Intake 2000-3000cc/day and high fiber diet promote elimination; reduced fluid slows the chymes passage along the colon - chime becomes drier than normal resulting in hard feces; reduced fluid also slows chymes passage along the intestine further increasing reabsorption of fluid. Ideally want 25 - 30 g fiber from fruit/veg/grains. If less fiber = less BM - Food intolerance may impact - e.g. lactose intolerant - may get gas and cramping and diarrhea; eg. Gluten intolerance - cant digest carbs and fats so get distention & bloating and diarrhea Daily routine - time, position, place. Hospital less conducive to bowel elim; - if IGNORE the urge - defication reflex goes away; leads to constipation . Hemrhoids - enlarged or varicose veins in the anal canal - can make deficating painful Activity - stimulates peristalsis; increases muscle tone and GI motility; bed bound patients are often constipated Body position - sitting is best... allows gravity to help and makes it easier for person to contract muscles.... Hard in bedpan Pregnancy - often constipated;

Factors Affecting Voiding

Age: Older adult = may experience urgency (a need to empty bladder more frequently); often have nocturia (need to pee at night) Alcohol increases urine as it slows production of ADH while caffeine drinks increase urine production Foods and meds can change color of urine (Pyridium) Body fluid - if person loses fluid eg. Vomiting, diarrhea, excessive diaphoresis re: fever or sweating, burns, blood loss pee less Body position - eg men usually pee best when standing; hard to pee when lying flat in bed. Cognition - may not realize need to pee Psychological - simply thinking about voiding can influence the process; hearing about it (or running water). Pouring warm water over the inner thigh...just as giving a person a cold bedpan can delay. If stressed - may need to pee more or less. Nurses may not void all day because too busy Circumstances may not be conducive to void - time, privacy Neurologic: - eg trauma, injury to frontal lobe of brain can lead to incontinence; may get reflex voiding - occurs when bladder as soon as it's stretched to a certain degree let's go - and person pees called reflex neurogenic bladder Obstructions: Urinary stone can block ureters; BPH blocks urethra slowing urine flow and bladder emptying; catheters that are blocked; - if obstruction get hydronephrosis (distention of kidney pelvis can lead to permanent kidney damage)

NonInvasive Interventions for Flatulence

Ambulation knee chest position

assessing voiding

Assessment: what's normal? May need to use the term "peeing" not urinating and not micturating What does it look like Any changes Ileal conduit - this is also known as a urinary diversion - surgical procedure where normal pathway of urine elimination is changed. May have bladder removed = cystectomy; resulting in ileal conduit - urinary diversion..... Pee should look the same Any factors influencing the pattern And risks factors UTI, renal calculi, renal failure Changes in daily routine - exercise, diet, fluid new meds? Have you noticed any problems lately? - good place to start. Physical assessment: Inspect - lower abd - may see distended lower bladder (if 600 - 700 cc urine present) Inspect perineal area if severe dysuria and purulent drainage Palpate - to feel edge of bladder - but can be uncomfortable so do it gently if you have to. Ultrasound - non invasive

A nurse is evaluating a client's understanding of preventing catheter-associated urinary infections. What statement indicates a need for further teaching? A. Maintain a sterile closed-drainage system B. Always disconnect the catheter and drainage tubing Provide routine C. perineal hygiene, including cleansing with soap and water after defecation D. Prevent contamination of the catheter with feces

B.

implementation: Intervention for Altered Function

Behavioral Interventions Recommended first line treatment or urinary incontinence Include lifestyle modification, scheduled voiding regimen, pelvic floor muscle exercises Can be implemented independently Many times urinary incontinence can be managed with treatments that nurses can prescribe and implement independently. Behavioral interventions are recommended first-line treatment of urinary incontinence.

Micturition (urination)

Bladder is distended as it fills; stretch receptors trigger the micturition reflex Parasympathetic nerves stimulates the detrusor muscle to contract External urethral sphincter is under voluntary control; neurons originate in brain stem and cerebral cortex Called "urination" and "voiding" Urine collects in the bladder Pressure stimulates special stretch receptors in the bladder wall Stretch receptors transmit impulses to the spinal cord voiding reflex center Internal sphincter relaxes stimulating the urge to void (unconscious) If appropriate, the conscious portion of the brain relaxes the external urethral sphincter muscle Urine eliminated through the urethra 250 - 400 ml in bladder stimulate this process . Normally the external sphincter is contracted in a closed position so voiding can be voluntarily delayed. In children younger than 3 years, the micturition reflex leads to spontaneous urination.

bladder ultrasound

Bladder ultrasound is a noninvasive technology that can estimate the volume of urine in the bladder. (explain how it is done) Portable bladder ultrasound machines allow the nurse to obtian measurements at the point of care. It will also allow for post void residual to be checked. This will measure the amount of urine left in the bladder after voiding. The usual finding is 50 mL or less. The portable ultrasound machine has decreased the need to straight cath the patient to determine post void residaul thus decreasing the risk for infection.

important lab values to know

Blood Urea Nitrogen 10-20 mg/dL Creatinine 0.7-1.4 mg/dL Glomerular Filtration Rate (GFR) greater than 60 Creatinine Clearance (24-hr urine specimen) 110-150 mL/min Urine Osmolality (24-hr urine specimen) 250-900 mOsm/kg Urine specific gravity 1.010-1.025

Pt's w Ostomies Psychological Considerations

Body image changes Face a variety of anxieties and concerns Must learn how to manage stoma Cope with conflicts of self-esteem and body image Can be concealed with clothing but pt. aware of its presence Difficulty with intimacy/sexual relations Foul odors, leakage, spills and inability to control or regulate passage of gas and stool is embarrassing Ostomy support: United Ostomy Association National Foundation for Ileitis and Colitis

Nasogastric tube placement needs to be checked prior to instilling fluids or administering medications. The best way of assuring tube location is: A. Aspirating gastric fluid from the tube. B. Instilling air via syringe and listening with a stethoscope for a "whoosh" sound. C. Portable chest x-ray reading. D. Inserting the tube end into water and checking for bubbles.

C.

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.

Reagent strips (dipsticks) are most commonly used to test urine for: A. Creatinine B. Sodium C. Glucose D. Estrogen

C. glucose Rationale: Creatinine and estrogen are best measured by 24-hour urine specimen. Sodium is not included on reagent strip panels. Urine glucose is most commonly measured by reagent strip.

Catheter Care

Catheter irrigation principles Catheter care principles Post-removal assessments

Alterations in Bowel Function: Constipation

Constipation- less then 3 bm/week or what ever is less then the pt's regular pattern of elimination. Lots of causes . infrequent and sometimes painful passage of hard stools. occurs when feces move through the bowels too slowly or remain in the bowels too long. change in stool consistency and frequency. S/S: small, dry hard stools, abd. pain, distention. Concern is that straining associated with constipation is often accompanied by holding breath. This is the VALSALVA maneuver which can present serious problems to patients with heart disease, brain injuries, or respiratory disease. It increases intrathoracic pressure and vagal tone slowing the pulse rate (pt may faint).

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 diagnoses is most appropriate? A .Stress Urinary Incontinence B. Reflex Urinary Incontinence C. Functional Urinary Incontinence D. Urge Urinary Incontinence

D.

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.

Which of the following is an abnormal color of urine? A. straw B. amber C. dark amber D. transparent

D.

Risk Factors for Constipation

Decreased dietary fiber intake Large amounts of refined foods or low residue diet, low natural fibers Decreased fluid intake, less than 2000ml/d Continues to delay bowel evacuation Decreased physical activity Chronic stress Abuse of laxatives Side effects from medications Aging process-decreased motility Neurological conditions- spinal cord injury, tumors

Altered Urine Elimination

Dysuria - pain with urination Polyuria --- produce large amounts of urine (diuresis) Oliguria --- produce low urine output, less than 500 ml/day or 30 ml/hour Anuria --- little to no urine production Some terms to be familiar with: Dysuria: painful, difficult voiding caused by : stricture of urethra, UTI injury to bladder or urethra Polyuria called diuresis - can be from excessive intake or diabetes mellitus or chronic nephritis Oliguria may indicate impending renal failure If person is anuric less than 100 ml/24 hours, they need dialysis . Can avoid dialysis if 10% of one kidney functions