Urinary EliminationScientific Knowledge BaseUrinary elimination is the last step in the removal and elimination of excess water and by products of body metabolism. Adequate elimination depends on the coordinated function of _________________________, __________________, ___________________, and _________. The kidneys filter waste products of metabolism from the blood. The ­­­­­­­­­­­­______________________________________ from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra.KidneyThe kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver.Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance. The normal range of urine production is ______________________________. Please convert to CC/day.  Erythropoietin, produced by the kidneys, stimulates red blood cell (RBC) production and maturation in bone marrow. The kidneys play a major role in blood pressure control via the renin-angiotensin system, release of aldosterone and prostacyclin. The kidneys also affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form.UretersA ureter is attached to each kidney pelvis and carries urinary wastes to the bladder.BladderThe urinary bladder is a hollow, distensible, muscular organ that holds urine. The bladder has two portions, a fixed base called the trigone and a distensible body called the detrusor. The bladder expands as it fills with urine. How much urine can the bladder hold?UrethraUrine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence. The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area.Act of UrinationBrain structures influence bladder function.Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxationBladder wall stretching signals micturition center.Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.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.Factors Influencing Urination (See Box 46-1)Growth and development­­­­­­­­­­­_____________________________­­­____________________________Sociocultural factors_____________________________­­­____________________________Psychological factors_____________________________­­­____________________________Personal habits_____________________________­­­____________________________Fluid intake_____________________________­­­____________________________Pathological conditions_____________________________­­­____________________________Surgical procedures_____________________________­­­____________________________Medications_____________________________­­­____________________________Diagnostic Examinations_____________________________­­­____________________________Common Urinary Elimination ProblemsThe most common problems involve _____________________________________________ or ________________________________________. Problems can result from1. I_____________________________­­­____________________________2. I_____________________________­­­____________________________3. O_____________________________­­­____________________________4. I_____________________________­­­____________________________5. I_____________________________­­­____________________________Urinary retention_____________________________­­­____________________________Urinary tract infection_____________________________­­­____________________________CAUTIsUrinary incontinence_____________________________­­­____________________________Common forms of UI are: (See Table 46-1)1. T_____________________________­­­____________________________2. F_____________________________­­­____________________________3. U/O_____________________________­­­____________________________4. S_____________________________­­­____________________________5. U_____________________________­­­____________________________6. R_____________________________­­­____________________________Urinary diversion­­­­­­­­­­­­­­­­­­­______________________________________________________________Two types: _____________________________________________________________A ureterostomy or ileal conduitNephrostomy tubesNursing Knowledge Base:________________________________________________________________Infection control and hygiene______________________________________________________Growth and development_________________________________________________________ (Focus on older adult Box 46-2)Psychosocial considerations________________________________________________________Critical thinking________________________________________________________________________Nursing Process: Assessment (Box 46-5)Through the patient’s eyes_________________________________________________________Self-care ability_______________________________________________________________Cultural considerations____________________________________________________________(Box 46.4 cultural aspects of care)Health literacy_______________________________________________________________Nursing history_______________________________________________________________(Box 46.5 Nursing assessment questions)Pattern of urination _____________________Symptoms of urinary alterations: (table 46-2) ___________________________________Physical assessmentKidneys___________________________________Bladder___________________________________External genitalia and urethral meatus___________________________________perineal skin___________________________________Assessment of urineIntake and output___________________________________Characteristics of urine___________________________________Color___________________________________Clarity___________________________________Odor___________________________________External genitalia and urethral meatusPerineal skinLaboratory and Diagnostic TestingDiagnostic Examination (Table 46.5 Common diagnostic tests of urinary Tract)Nursing responsibilities before testing:1. ___________________________________2. ___________________________________3. ___________________________________4. ___________________________________Responsibilities after testing include:1. ___________________________________2. ___________________________________3. ___________________________________Nursing Diagnosis: Nursing diagnoses common to patients with urinary elimination problems:Functional urinary incontinenceStress urinary incontinenceUrge urinary incontinenceRisk for infectionToileting self-care deficitImpaired skin integrityImpaired urinary eliminationUrinary retentionPlanningGoals and outcomesSet realistic and individualized goals along with relevant outcomesCollaborate with the patientSetting priorities___________________________________________________________Patient’s immediate physical and safety needsPatient expectations and readiness to perform some self-care activitiesTeamwork and collaboration______________________________________________________ImplementationHealth promotion_____________________________________________________Patient education_____________________________________________________Promoting normal micturition_______________________________________________• Maintaining elimination habits• Maintaining adequate fluid intakePromoting complete bladder emptying______________________________________________Preventing infection____________________________________________________Acute careCatheterization____________________________________________________­­­­­______________Skill 46-2, Inserting and Removing a Straight (Intermittent) or Indwelling CatheterTypes of catheters _____________________________________________________________________Catheter sizes_____________________________________________________________________Catheter changes_____________________________________________________________________Catheter drainage systems____________________________________________________________________Routine catheter care_____________________________________________________________________Preventing catheter associated infection (Box 46-10) _____________________________________________________________________Catheter irrigations and instillations_______________________________________________________Removal of indwelling catheters__________________________________________________________Alternatives to catheterization____________________________________________________________Suprapubic catheters External cathetersUrinary diversionsØ Incontinent diversionsChanging a pouchGently cleanse the skin surrounding the stomaMeasure the stoma and cut the opening in the pouchRemove the adhesive backing and apply the pouchPress firmly into place over the stoma.Observe the appearance of the stoma and surrounding skin.Continent diversionsOrthopic neobladderMedicationsAntimuscarinics: treat urgency, frequency, nocturia and urgency UIBethanechol: treat urinary retentionTamsulosin and silodosin: relax smooth muscleFinasteride and dutasteride: shrink the prostateAntibiotics: treat urinary tract infectionsBe familiar with the medications and indications for all medications your patient is taking.Continuing and restorative careLifestyle changesPelvic floor muscle trainingBladder retrainingToileting schedulesIntermittent catheterization• Skin careEvaluationThrough the patient’s eyesAssess the patient’s self-image, social interactions, sexuality, and emotional statusPatient outcomesUse the expected outcomes developed during planning to determine whether interventions were effectiveEvaluate for changes in the patient’s voiding pattern and/or presence of symptomsEvaluate patient/caregiver compliance with the planSafety Guidelines for Nursing SkillsFollow principles of surgical and medical asepsis as indicatedIdentify patients at risk for latex allergiesIdentify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.Bowel EliminationScientific Knowledge Base_______________________________________________________________Mouth_____________________________________________________________________Esophagus_____________________________________________________________________Stomach_____________________________________________________________________Small intestine__________________________________________________________________Large intestine__________________________________________________________________Anus_____________________________________________________________________Defecation_____________________________________________________________________Nursing Knowledge Base: Factors Affecting Bowel EliminationAge_____________________________________________________________________Diet_____________________________________________________________________Fluid intake_____________________________________________________________________Physical activity_____________________________________________________________________Psychological factors___________________________________________________________________Personal habits_____________________________________________________________________Position during defecation_______________________________________________________________Pain_____________________________________________________________________Pregnancy_____________________________________________________________________Surgery and anesthesia_________________________________________________________________Medications_____________________________________________________________________Diagnostic tests_____________________________________________________________________Common Bowel Elimination Problems_____________________________________________________Constipation (Box 47-1) ________________________________________________________________Impaction____________________________________________Diarrhea_____________________________________________________________________Incontinence_____________________________________________________________________Flatulence_____________________________________________________________________Hemorrhoids_____________________________________________________________________Bowel DiversionsTemporary or permanent artificial opening in the abdominal wall. Stoma­­­­­­­­­___________________Surgical opening in the ileum or colon. Ileostomy or colostomyOstomiesSigmoid colostomyTransverse colostomyIleostomyLoop colostomyEnd colostomyOther ApproachesIleoanal pouch anastomosisContinent ileostomyAntegrade continence enemaCritical ThinkingIntegrate the knowledge from nursing and other disciplines to understand the patient’s response to bowel elimination alterations.Experience in caring for patients with elimination alterations helps you provide an appropriate plan of care.Use critical thinking attitudes such as fairness, confidence, and discipline.Apply relevant standards of practice when selecting nursing measuresNursing Process: AssessmentThrough 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.Elimination factors(Box 47.3 Nursing assessment questions)Elimination patternStool characteristicsRoutinesBowel diversionsAppetite changesDiet historyDaily fluid intakeSurgery or illnessMedicationsEmotional stateExercisePain or discomfortSocial historyMobility and dexterityPhysical assessmentMouthAbdomenRectumLaboratory tests: Fecal specimensDiagnostic examinations:Direct visualizationIndirect visualizationBowel preparationNursing Diagnosis: Some diagnoses that apply to patients with elimination problems include:Disturbed body imageBowel incontinenceConstipationPerceived constipationRisk for constipationDiarrheaNauseaDeficit knowledge (nutrition)PlanningGoals and outcomesIncorporate elimination habits or routinesReinforce routines that promote healthConsider preexisting concernsSetting prioritiesPatients often have multiple diagnosesTeamwork and collaborationImplementation: Health PromotionRoutineColorectal cancerPromotion of normal defecationSitting positionPrivacyPositioning on bedpanPrevent muscle strain and discomfortElevate head of the bed 30 to 45 degreesWear gloves when handling bedpansAcute CareEnvironmentCathartics and laxativesØ Cathartics have a stronger and more rapid effect on the intestines than laxativesØ Suppositories may act more quickly than oral medicationsAntidiarrheal agentsOpiates used with cautionEnemasCleansing enemasTap waterNormal salineHypertonic solutionsSoapsudsOil retentionOther types of enemasCarminative and KayexalateEnema administrationSterile 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 stoolUse if enemas fail to remove an impaction.Last resort in managing severe constipationInserting and Maintaining a Nasogastric TubePurposes• Decompression, enteral feeding, compression, and lavageCategories 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 secretionsClean techniqueMaintaining patencyContinuing and restorative careCare of ostomies______________________________________________________Irrigating a colostomy______________________________________________________Pouching ostomies______________________________________________________Nutritional considerations______________________________________________________Psychological Considerations______________________________________________________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 ______________________________________________________EvaluationThrough the patients eyes­­­­­­­­­­­­­_______________________________________________________Patient outcomes ____________________________________________________________1. Medication Ordersa. What are the nursing responsibilities for acknowledging or checking orders?b. List the components of a correctly written medication order.c. Explain and define the different types of ordersi. Standingii. Statiii. PRNiv. Single2. Routes of Administration – define and discuss nursing considerations for each:a. Enterali. Oralii. Sublingualiii. Buccaliv. G-Tube/NGTv. Rectalb. Parenterali. SQ· Angle of insertion:· Sites of administration:ii. IM· Angle of insertion:· Sites of Administration:iii. ID· Angle of insertion:· Sites of Administration:iv. IVv. What is the purpose of the Z-track method? When is it performed?c. Topicali. Eye Dropsii. Eardropsiii. Nasal dropsiv. Inhalersv. Lotion/cream/ointment/powdervi. Transdermalvii. VaginalCritical Thinking Scenario:The patient, Mr. Koop, has deteriorated over the shift. His temp is now 39.2 C, he is complaining of nausea and is not able to tolerate oral fluids. The nurse checks the orders for Mr Koop and finds that he is ordered acetaminophen 650mg po q4hrs for temps >38.5 C. Based on the assessment of the patient, what would be the nurse’s next action?3. Define each of the Rights of Administration:a. Medicationb. Dosec. Patientd. Routee. Timef. Documentationg. Indicationh. Responsei. Refuse4. Explain the Checks of Medication Administrationa. Firstb. Secondc. ThirdCritical Thinking Scenario:A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route?5. Define medical reconciliation and explain when it would occur.6. When would a nurse refuse to administer a drug?Critical Thinking Scenario:The healthcare provider enters an order a new medication, Acetaminophen 2g po q4hrs prn pain into the EMAR. Pharmacy fills the order and sends it to the floor. The patient is requesting pain meds for a pain level of 4/10. The nurse reviews the order and questions it. Why does the nurse question the order? What would the nurse do next?7. Developmental Considerationsa. Infants/Childrenb. Elderly8. Other Considerations for Med Administrationa. How does the nursing assessment figure into med administration?Critical Thinking Scenario:A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What will the nurse do?Critical Thinking Scenario:The patient’s medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What will the nurse do?9. Name at least 5 ways a medication error can occur. What is the priority when a medication error happens?10.  Name at least 5 assessment questions the nurse should ask before giving medication?11. How do you draw up two medications? Please write the steps.12.  What do you have to be cautious of when crushing oral medication?13. Name the parts of a syringe.14. Needles come in various gauges. The ___________the gauge number, the smaller the needle.15. How do you remove medication from a vial? Ampule?16. In what part of the eye are eye drops applied?17. How do you hold the ear when applying ear drops in infants? How do you hold the ear when applying ear drops in an adult?18. Does the nurse need to put on gloves when applying a transdermal patch? Why?19. When giving a subcutaneous injection (SQ) in the abdomen, be sure to choose a site at least ____ inches away from the umbilicus.20. Why do you need to rotate sites when applying transdermal patches?Critical Thinking Scenario:The nurse is preparing to administer a transdermal patch to a patient and finds that the patient already has a medication patch on his right upper chest. What will the nurse do?Critical Thinking Scenario:The nurse is giving a medication that has a high first-pass effect. The health care provider has changed the route from PO to IV. What can the nurse expect with the IV dose?Critical Thinking Scenario:The nurse answers a patient’s call light and finds the patient sitting up in bed and requesting pain medication. What will the nurse do first?Class Prep Guide Part I1. Define:a. Pharmacologyb. Pharmacotherapeuticsc. Pharmacokineticsd. Pharmacodynamics2. How are Drugs Classified?· What is the difference between them?· Why do nurses need to know about pharmacology?3. Define:a. Absorptionb. Distributionc. Metabolismd. Excretion4. Factors affecting Absorptiona. Dosageb. Dosage Formi. Enteric coatedii. Extended releasec. Define the Routesi. Parenteralii. Enteraliii. Topicald. GI functionIdentify the administration route (be specific):____ Injection just below the dermis of the skin____ Drops placed directly into the eye or ear____ Medication placed in the mouth against the mucous membrane____ Injection into a vein____ Medication placed under the tongue____ Medicated packing placed in rectum____ Injection into the muscle____ Ointment placed directly on the skin____ Injection into the dermis just under the epidermis5. Factors affecting Distributiona. Blood Flowb. Blood Brain Barrier6. Factors affecting Metabolisma. First pass effecti. Which medication, oral Tylenol or IV Tylenol, has a higher bioavailability level? Why?b. Protein Binding7. Drug Action on the Cella. Stimulate cell functionb. Inhibits cell function8. Identify the following potential problems/impairment as affected by absorption (A), distribution (D), metabolism (M), or excretion (E):____ Impaired blood flow____ End stage renal disease____ Elderly population____ Medication given with a large meal____ Liver disease____ Blood-brain barrier____ Continuous gastric suctioning9. A patient who has had gastric bypass surgery may have difficulty with which aspect of pharmacokinetics?10. Define the Phases of Clinical Trialsa. Phase Ib. Phase IIc. Phase IIId. Phase IVIdentify the clinical trial phase for the following:- A larger number of patients receive the medication at a higher dose ______- Medication is given to a large number of patients and results are compared with the standard-of-care medication_____- A small number of patients receive a low dose of medication to evaluate its safety________- Medication is made available to the general public and effectiveness and side effects of the drug are tracked _____11. Sources of Drugs12. Names of Drugsa. Chemicalb. Genericc. Trade/Brand13. Provide the chemical, generic, and a trade name for the following:· azithromycin· diphenhydramine· meloxicamCritical thinking exercise:Sarah Hawkins, an older woman who lives on a fixed income, is on multiple medications. She says that all her friends are taking the generic form of their medications. While you, the nurse, are visiting her, she asks, “What do you think of generic medications? Are they safe? Are they as good? Are they worth it?” Answer the following questions:How do generic equivalent drugs differ from a trade name drug?What would you, the nurse, recommend that Sarah do about accepting generic drugs?14. Drug Standardsa. FDAb. US Pharmacopeiac. National Formularyd. Hospital Formularye. Physician’s Desk Referencef. Prescriptiong. OTC (Over the Counter)· What is the role of the FDA?· What role does the FDA play in regulating herbal and dietary supplements?15. Drug Monitoringa. Therapeutic drug monitoringb. Half-lifec. Onset· Why is a drug’s half life listed in a drug reference book?· When is the use of drugs with short half lives indicated?d. Peak & Troughe. Minimum Effective Concentrationf. Therapeutic Rangeg. Toxicity·Scenario: 2 mg of IV Morphine is given to an adult at 1000 for severe 10/10 pain. The patient starts to feel the effect at 1005. At 1020 the patient reports their pain as 3/10 and reports relief of pain until 1430.What is the onset? _____________ When is the peak? _____________What is the duration? ___________·Scenario: IV Vancomycin infusion is started at 0800 and is infused over 1 hour.When would the nurse measure the trough level? ________When would the nurse measure the peak level? __________·Scenario: Acetaminophen has a half-life of 3 hours for adults.If 500 mg is given at 0800, how much of the drug will have been excreted at 1100? ____How much at 1400? ____When would the drug be completely excreted from the system? _____16. Pharmacodynamicsa. Potencyb. Efficacyc. Agonistd. Partial agoniste. Antagonist·Scenario: A 26-year old patient takes 20 tablets of oxycodone by mouth. The nurse gives the patient naloxone.· What is the agonist? The antagonist? How does the antagonist work?· How would you teach the patient the difference between potency and efficacy?f. Drug to Drug Interactionsi. Additive effectii. Antagonistic effectiii. Synergistic effectiv. Incompatibility· Differentiate between additive, synergistic and antagonistic drug effects.g. Drug Diet Interactions17. Identify the food the patient should avoid when taking the following medications and why should it be avoided:· Ciprofloxacin· Atorvastatin· Warfarin18. Variable affecting Drug actiona. Ageb. Genderc. Disease processd. Ethnicitye. Geneticf. Dosage·Scenario: John Kessler has been ill for a long time and his prognosis is poor. He is 84 yrs old with multiple debilitating and chronic conditions. He has had uncontrolled diabetes for more than 20 yrs and has experienced many complications due to this condition. Three years ago, he developed chronic kidney disease and requires dialysis 3 times a week. To further complicate his condition, John has continued to consume alcohol every day and smokes one pack of cigarettes per day. He has a long history of both alcohol and tobacco use.Five days ago, his daughter noticed he was becoming increasingly weak and lethargic. Last night when his temp reached 38.8C ( 102F) and he became confused, he was taken to the ER and admitted to the hospital. A chest xray this morning revealed bilateral pneumonia. John is receiving multiple medications through both the IV and inhalation route.What factors may influence drug metabolism or excretion in this patient?How would drug elimination for this patient possibly complicate the pharmacotherapy?How will IV or inhalation drug therapy affect the absorption of his medications?John will receive a loading dose of IV antibiotics and then receive a maintenance doses every 6 hrs. What is the purpose of this regimen?·Scenario: Percocet is given to an 89- year old female, weighing 98 lbs. with a history of end-stage renal disease, hypertension, and arthritis is admitted for pain management following a fall. Identify the variables which might influence absorption of the po medication. What else would the nurse want to know?19. Pregnancy Categoriesa. Define each category:i. Aii. Biii. Civ. Dv. Xb. Teratogenic effects20. Drug Effects: Define each term:a. Therapeutic effectb. Side effectc. Adverse effectd. Drug toxicitye. Drug allergyf. Anaphylaxisg. Drug toleranceh. Drug dependencei. Cumulative effectj. Idiosyncratic effectk. Addiction21. Identify the following as a therapeutic effect (TE), a side effect (SE), a drug allergy (DA), an anaphylactic reaction (AR), or an idiosyncratic effect (IE)____ Sudden constriction of the bronchiolar muscles and edema ofthe larynx____ Administration of Benadryl results in unexpectedhyperactivity in a child____ Antihypertensive medication lowers blood pressure to WNL____ Administration of antibiotic medication results in nausea____ Administration of IV morphine results in hives and itching22. Pharmacotherapeuticsa. Maintenance therapyb. Prophylactic therapyc. Therapeutic index·Scenario: A patient who takes warfarin for chronic atrial fibrillation and is going in for a knee replacement.· What test might the doctor order to check the therapeutic index?· What type of medication might the doctor order prior to surgery?· Is warfarin considered maintenance therapy? Why or why not?·Scenario:As the triage nurse in a busy ER, you determine the patient’s chief complaint, obtain vital signs, collect past medical history and ask about food and drug allergies. While assessing a patient with a suspected ankle fracture, the patient says that they are allergic to codeine because it makes them sleepy and nauseated.· What further questions would you ask the patient about drug allergies?· Differentiate between an adverse effect, a side effect and a drug allergy. Which does this patient have?· Is this patient experiencing an idiosyncratic reaction?

 

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