Unit 4 Fundamentals

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daily weights - same time every day, same clothes on monitor VS I&O restrict fluids diuretics admin O2 monitor lung sounds

NI associated with fluid volume excess

isotonic, so it's the safest solution

a normal saline enema is

loop colostomy

- a loop of bowel is brought to stomach surface so there are two stomas - temporary, get in fast - proximal and distal stomas

colostomy

- a part of large intestine is brought to the abdominal wall - stool could come from the ascending, transverse, descending, and sigmoid depending on where the stoma is - if the stool is coming from the ascending, it will be more liquid - if the stool is coming from the sigmoid, it will be more solid (the closest to the rectum, the more solid the stool is)

nocturia

- awakening to void 1 or more times per night - sx of BPH in men

functional urinary incontinence

- cognitive or functional impairment (dementia, sedation, or mobility) - not able to think - pts with arthritis or who have had strokes don't have physical ability to get clothes down in time to use bathroom

kock continent ileostomy

- created artificial reservoir that sits inside pt - collects liquid stool - create special type of stoma that keeps stool in there - pt periodically uses catheter to suck out stool every few hours - doesn't need to wear bag - may need to wear bag when pt first gets it until it is healed

double barrel colostomy

- created two stomas but the loop is cut - both ends are brought to stomach wall - proximal and distal stomas

reflex urinary incontinence

- damage to the spinal cord - pts lose control to urinate completely

ileostomy

- large intestine is gone - stool is coming from small intestine - stoma is created by bringing piece of small intestine to the abdominal wall

timed collection

- may have to collect urine over certain time frame (24hr, 12hr, 2hr, depending on the test) - catch all urine that pt pees out within that period of time - urine goes in special jug - when it is time for collection to start, have the pt pee into toilet, flush it, then collect urine every time the pt pees after that. - measure it and put it into container - don't want toilet tissue or stool in it - make sure pt knows you have to collect all their urine within the ordered time frame

paralytic ileus

- no peristalsis at all - expected 24-48hr after surgery

random urine collection

- routine urinalysis - clean cup - not sterile - collect it out of hat, bed pan, from catheter, cup, etc - put in a biohazard bag, label it, send it to the lab - get it to the lab within 1 hr - don't leave it out in room temp for over an hour - can be refrigerated for up to 8 hr

ileoanal pouch reservoir

- take ileum and creates artificial rectum - connect it to pt's anus - once it heals, pt will pass stool through rectum and have control - more liquid stool - immediate post op: pt might have to wear pouch until it heals, take away pouch

clean-voided specimen/ midstream

- trying to get as clean and sterile as we can - use a sterile cup - put inside of lid facing up - men: start cleaning a tip of penis in circular motions going down, repeat using all 3 swabs once - start to urinate into toilet first, then hold cup under to urinate into it so that you are getting urine from the bladder. - women: clean from front to back, spread labia, cleaning next to urethra, first wipe down, next down the other side, then down the center. start to pee in the toilet then into the cup midstream

urge incontinence

- unable to suppress the sudden need to urinate; usually from infection (UTI) irritating the bladder, diuretics - pt knows he or she has to go but just can't get there in time

1. can lose just water with fever, hyperventilation, etc 2. loss of water and electrolytes in pts who are vomiting, have diarrhea, sweating, GI suctioning

2 types of fluid volume deficit:

c. metabolic acidosis

Mr. Jones is experiencing confusion, Kussmaul's respirations, restlessness, dysrhythmias and diarrhea. he is in: a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis

daily weights I&O oral hygiene force fluids IV fluids monitor VS, lab results, and oxygen levels

NI associated with fluid volume deficit

BRAT or low residue diet (low fiber - no nuts, seeds, fresh fruits, whole wheat) may need meds such as antibiotics, antidiarrheals, anti-inflammatories encourage fluids or admin IV fluids (with potassium supplementation) avoid excessively hot or cold foods because they increase peristalsis perianal skin care with mild soap, peri cleanser - use moisture barrier Fecal management system - drains liquid stool, measures output, prevents turning & repositioning

Nursing Interventions associated with diarrhea

d. grape and walnut chicken salad sandwich on whole wheat bread

a nurse is assisting a pt in making dietary choices that promote healthy bowel elimination. which menu option should the nurse recommend? a. turkey and mashed potatoes with brown gravy b. dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing c. broccoli and cheese soup with potato bread d. grape and walnut chicken salad sandwich on whole wheat bread

a. discussing with the client and family the plan of care and fluid restriction d. providing a collection device for measuring the client's urinary output

a nurse is caring for a pt with with renal insufficiency. in addition to an ordered fluid restriction, the client needs strict monitoring of intake and output. which actions should the nurse plan to include when caring for the client? select all that apply. a. discussing with the client and family the plan of care and fluid restriction b. documenting pureed foods as part of the client's liquid intake c. eliminating counting ice chips as intake because this represents such a small amount of intake d. providing a collection device for measuring the client's urinary output e. instructing the family to record any intake they provide to the client on the facility intake record f. encouraging the family to bring favorite foods and drinks from home for the client to consume

c. limit fluid and caffeine intake before bed

a patient has fallen several times in the past week when attempting to get to the bathroom. the pt informs the nurse that he gets up 3 or 4 times a night to urinate. which recommendation by the nurse is most appropriate in correcting this urinary problem? a. clear the path to the bathroom of all obstacles before bed. b. leave the bathroom light on to illuminate a pathway c. limit fluid and caffeine intake before bed d. practice kegel exercises to strengthen bladder muscles

d. perform pelvic floor exercises

a pt asks about treatment for urge urinary incontinence. the nurse's best response is to advise the pt to a. wear an adult diaper b. avoid voiding frequently c. drink cranberry juice d. perform pelvic floor exercises

Cardiovascular disease ICP increased pressure in eyes

a pt with ____, _____, _____ should not strain when having a bowel movement

residual urine

amount of urine left in the bladder after voiding

b. continuous urine

an ileal conduit is performed on the pt who has a cystectomy. what type of drainage will the pt have from the stoma? a. formed feces at periodic intervals b. continuous urine c. intermittent urinary drainage d. continuous liquid fecal material

urinary retention

bladder is not able to empty

concerned if pt gains 2 pounds over night or 5 pounds in a week

cause of concern associated with weight gain due to fluid volume excess

< 30 mL

cause of concern is ______ of urine per hour

dehydration diet low in fiber decreased GI motility decreased mobility narcotics surgery post op sedatives anticholinergics antidepressants iron and calcium neuropathy

causes of constipation?

infection malabsorption or inflammatory bowel diseases drug SE (antibiotics) enteral feedings lactose intolerance surgery or diagnostic testing of the lower GI

causes of diarrhea?

blood loss dehydration diuretics vomiting diarrhea hyperglycemia (develops polyuria) NPO draining wounds

causes of fluid volume deficit

excessive intake of fluids (PO or IV) excessive intake of salty foods renal failure steroids

causes of fluid volume excess (overload)

urethral obstruction surgical or childbirth trauma spinal anesthesia neuropathy trauma 2nd to indwelling catheters medications (anticholinergics, antidepressants) enlarged prostate

causes of urinary retention?

brown in color odor should poop at least 2-3 times a week should be shaped like rectum soft painless when passed may see undigested food

characteristics of normal stool

impaction

collection of hardened feces in the rectum that can't be expelled (can partially or completely cause inability for stool to pass

oliguria

decreased urine output despite normal intake - drinking normally, but making less urine

- lubricates the rectum and colons - helps to ease passage of stool, softens stool - retain solution for several hours if possible

describe oil retention enemas

- put warm water first, then add soap, mix it up - only use castile soap - it can cause intestinal irritation, stimulates peristalsis - use cautiously with pregnant women and older adults because it can cause electrolyte imbalances - fill container with solution and then add soap

describe soapsud enemas

- most common type - leak when straining the abdomen such as coughing, sneezing, lifting, laughing - obesity can cause it - seen with women after having vaginal delivery - seen with men who had prostate surgery or BPH

describe stress incontinence

- hypotonic (number of particles in tap water is less than particles in body), so tap water escapes from bowel lumen into interstitial spaces - can lead pt into fluid overload and mess up electrolyte imbalance - do not repeat tap water enemas - fluid shifts out of intestine, goes into cells and makes the swell, get bigger and round

describe tap water enemas

dehydration - lose lots of electrolytes --> hypokalemia acidosis - pH drops electrolyte imbalance skin breakdown

diarrhea results in:

pt with ICP glaucoma recent rectal or prostate surgery

enemas are contraindicated in

treat constipation remove impaction empty bowel before diagnostic test or surgery bowel training administering meds

enemas can be given to

every 1kg that the pt gains = _____ of fluid

polyuria

excessive urine output

750-1000 mLs

for an adult cleansing enema, use ___-_____ mLs

- admin the enema in pt's colon - hold solution 12-18 inches above pt - have pt turn from the left lateral to the dorsal recumbent and over to the right lateral - fluid reaches large intestine

how to give high cleansing enemas

- fluid cleanses only the rectum and sigmoid - goes into rectum - solution should be held about 3 inches above pt

how to give low cleansing enemas

- fleet enema - small volume enemas - has a lot more particles than in regular body system - pulls fluid from interstitial spaces into the colon - usually low volume - warm it with warm water - contraindicated with dehydrated pt or young infants - can lead to dehydration or worsen dehydration - pulls water out of body and into colon

hypertonic solution enemas

constipation

infrequent and difficult passage of stool

1200-1500mL per day

kidneys excrete ______-______mL/day

anuria

no urine produced

1200-1500 mLs of urine

normal daily output of urine

encourage fluids adequate fiber in diet: whole grains, dried beans, fruit, veggies exercise scheduled bathroom time - after meals (most peristalsis occurs) provide privacy proper positioning do not postpone urge to defecate meds: fiber, stool softeners, laxatives enemas

nursing interventions for constipation

diarrhea

passage of unformed, liquid or narrow pencil shaped stool with increased frequency - softer, more liquid

caffeine carbonated beverages aspartame citrus fruits/juices tomatoes chocolate spicy foods

pt with urinary incontinence should avoid bladder irritants such as

the more concentrated the urine is, the more irritating it is to the bladder, the greater the risk for urgency

pts with urinary incontinence should consume adequate fluids because

<50 mL

residual urine should be ______

frequency less than every 3 days hard stool feeling of rectal pressure straining to pass stool - Valsalva maneuver

sx of constipation

thirst weight loss dry mucous membranes poor skin turgor decreased urine output low grade temperature increased HR thready pulse low BP increased RR increased urine specific gravity (>1.03) increased Hct increased BUN oliguria with dark urine longitudinal furrows in tongue restlessness confusion serum osmolality goes up

sx of fluid volume deficit

edema (peripheral, ascites) pulmonary edema (SOB, cough crackles) JVD weight gain decreased or low BUN low Hct bounding pulses periorbital edema (in renal failure) increased RR O2 levels go down creatinine might go down BP might go up

sx of fluid volume excess

no stool for several days with urge to defecate continuous oozing of diarrhea stool anorexia distension cramping rectal pain

sx of impaction

bladder distension absence of urine for several hours may see retention with overflow of 25-60mL voiding several times per hr without any relief

sx of urinary retention

c. check weight daily (best way)

the best method to assess the restoration of fluid volume in a pt who has been dehydrated is to a. monitor blood pressure b. observe changes in skin turgor c. check weight daily d. assess oral mucous membranes

c. donning gloves for digital removal of the stool (treatment of impaction) *never repeat tap water enemas

the nurse has attempted to administer a tap water enema for a pt with fecal impaction with no success. what is the next priority nursing action? a. inserting a rectal tube b. positioning the pt on the left side c. donning gloves for digital removal of the stool d. preparing the pt for a second tap water enema

b. mastication triggers the digestive system to begin peristalsis

the nurse is caring for a pt who is confined to the bed. the nurse asks the pt if he needs to have a bowel movement 30 minutes after eating a meal because a. the digested food needs to make room for recently ingested food b. mastication triggers the digestive system to begin peristalsis c. the smell of bowel elimination in the room would deter the pt from eating d. more ancillary staff members are available after meal times

c. "I can usually keep my ostomy pouch on for 3-7 days before changing it." d. "I must use a skin barrier to protect my skin from urine."

the nurse is evaluating the discharge teaching for a client who has an ileal conduit. which of the following statements indicates that the client has correctly understood the teaching ? select all that apply. a. "if I limit my fluid intake, I will not have to empty my ostomy pouch as often." b. "I can place an aspirin tablet in my pouch to decrease odor." c. "I can usually keep my ostomy pouch on for 3-7 days before changing it." d. "I must use a skin barrier to protect my skin from urine." e. "I should empty my ostomy pouch of urine when it is full."

d. special skin care is a priority

the nurse is working with the client who has an ileostomy. included in the plan of care for this client is instruction that: a. special clothing will need to be ordered to fit around the diversion b. a stomal bag will need to be worn only at night c. a reduction in physical activity will be planned d. special skin care is a priority

b. placing the drainage bag on the side rail of the pt's bed (urine can backflow into bladder)

the nurse knows that which indwelling catheter procedure places the pt at greatest risk for acquiring a urinary tract infection a. failing to secure the catheter tubing to the patient's thigh b. placing the drainage bag on the side rail of the pt's bed c. kinking the catheter bag tubing to obtain a urine specimen d. emptying the drainage bag every 8 hours or when half full

d. 2000 mL

the nurse makes the evaluation that the intake of one of the adult clients in her care is adequate when she measures the total daily intake as a. 750 mL b. 900 mL c. 1000mL d. 2000 mL

less than 30 mL

the nurse should call the physician if the pt is having urinary output of ______ per hour

digital removal of stool with physician order

tx for impaction

opioids anticholinergics iron

types of meds that are very constipating

d. "when was the last time you voided?"

upon palpitation, the nurse notices that the bladder is firm and distended; the pt expresses an urge to urinate. the nurse should follow up by asking a. "do you have a fever or chills?" b. "have you noticed any change in your urination patterns?" c. do you lose urine when you cough or sneeze?" d. "when was the last time you voided?"

age diet fluid intake (not drinking enough, not enough fluid in body = dryer harder stools) physical activity (walk to increase peristalsis, decrease gas) weakened abdominal or pelvic floor muscles psychological factors (stress increases peristalsis) personal habits (ignoring urge to poop, more water is reabsorbed, leads to dryer harder stools

what are some factors influencing bowel elimination?

1. just retaining too much water (SIADH) = over hydrated 2. retaining too much water and sodium (ex: kidney disease)

what are the 2 types of fluid volume excess?

- polystyrene - retention enema for hyperkalemia - binds with potassium and the pt poops it out to decrease potassium levels - neomycin - decreases infection in pt that is about to have bowel surgery

what are the medicated enemas and what do they do?

- continue to give enema over and over until there is no more solid stool - used for colonoscopy or colon surgery - cannot do more than 3 because it can cause fluid shifts

what does enemas until clear mean?

- used to reduce flatus and pass stool - has small amount of water, glycerin, and magnesium

what is a carminative enema used for?

stress

what is the most common type of urinary incontinence ?

c. evaluate client for normal voiding

what is the priority of care after the urinary catheter is removed? a. encourage client to eliminate fluid intake b. document size of catheter and client's tolerance of procedure c. evaluate client for normal voiding d. documentation of client teaching

normal saline because it has the same concentration of particles as body fluids - used to prevent fluid shifts

what should you use inside an enema and why?

colostomy