Fund 50 week 3 - day 1.2 - elimination

Question 1

Upper urinary system: (just amount per kg)

Answer 1

just ureter and Kidneys
Normal urine output: 0.5-1.5 mL/kg/hour.
women urethra - 2 inches
men - 6 - 8 inches

Question 2

Lower urinary system

Answer 2

Bladder and urethra.
❖(he didn’t even discuss this #, don’t worry about it) Avg bladder 500 ml of urine in women and 700 ml in men.

Question 3

function of kidneys(a wet bed p) (taking acid)

Answer 3

❖ A – Acid base balance (bicarbonate)
❖ W- Water balance
❖ E- Electrolyte balance via selective
reabsorption and excretion of electrolytes
and substances
❖ T –Toxin removal (Filters and excretes end
products of metabolic waste e.g. urea,
creatinine, ammonia, and uric acid)
❖ B- Blood pressure regulation via renin-
angiotensin system
❖ E- Stimulates Erythropoietin to produce
RBC
❖ D -Converts vitamin D on the skin to the
active form 1, 25- Vit D
❖ P – Protein regulation: albumin,
erythropoietin, and vitamin D-binding
protein.

Question 4

❖ Neurogenic bladder

Answer 4

result of neurological condition
❖ Spinal cord injury, neurodegenerative d/o, cauda equina

Question 5

Acute renal injury (AKI) (what drops, and what causes it - 2 things -either injuring it or blocking it)

Answer 5

❖ Acute drop in blood pressure
❖ Injury to the glomeruli or tubules
❖ Obstruction of kidney outflow leading to hydronephrosis

Question 6

Chronic kidney disease (CKD) (diseases that cause it - diabetes is chronic)

Answer 6

❖ Slow loss kidney function over months and years
❖ Caused by HTN - high blood pressure, DM, glomerulonephritis, heart failure

Question 7

ESRD - End Stage Renal Disease (what rises on blood test (what is always measured for kidneys), and what happens to ppl with ESRD?)

Answer 7

usually can’t make any urine
➢ chronic rise in serum creatinine leading renal failure
➢ requires life-long dialysis or renal transplant

Question 8

diagnostic lab of renal function(comprehensive)

Answer 8

MOST important thing to remember is you need comprehensive tests to assess renal function

BUN Byproduct from protein catabolism.
Cleared by kidneys, Not specific to
renal function
8-25 mg/dl
Protein breakdown, dehydration,
overhydration, liver failure influence
value

Question 9

Creatinine

Answer 9

Creatinine Byproduct of skeletal muscle cell
metabolism; evaluates nephron fcn
Men: 0.6-1.5 mg/dl
Women: 0.6-1.1

Question 10

Creatinine clearance Indicates GFR Men

Answer 10

Creatinine clearance Indicates GFR Men: 95-135 ml/min
Women: 85-125 ml/min

Question 11

GFR (what number is renal dysfunction)

Answer 11

GFR Identifies renal dysfunction > 60 ml/min. below 60 means kidney disease

Question 12

chronic kidney injury main causes - (the 2 you know well)

Answer 12

Progressive, irreversible loss of
kidney function
▪ DM and HTN leading causes
▪ ESRD is when GFR < 15mL/min
(at least 90 ml/min)
▪ GFR measures kidney function
▪ Based on creatinine level, age,
body size, gender, ethnicity

Question 13

Anuria (and when would you see this?)

Answer 13

Absence of urine production - End stage renal disease or sepsis

Question 14

Oliguria (olga is small)

Answer 14

❖ Oliguria – Urine < 30mL/hr
❖ Etiologies: AKI, dehydration, enlarged prostate

Question 15

❖ Polyuria (and what disorders)

Answer 15

Excessive urination
❖ May be associated with overhydration, DM, Diabetes
Insipidus, other kidney disease

Question 16

❖ Dysuria (and what causes it)

Answer 16

Painful or difficult urination
❖ Assoc with infection or urine obstruction (kidney stones)

Question 17

effects of aging (just loss of kidney function)

Answer 17

❖ Between ages 30 and 90
▪ Size and weight of kidneys ↓ by 20% to 30%
❖ By 7th decade
▪ Loss of 30% to 50% of glomerular function
❖ Atherosclerosis accelerates ↓ of renal size

Question 18

effects of aging 2 (ability to do what with urine?)

Answer 18

Physiologic changes
▪ ↓renal blood flow → ↓GFR
▪ Altered hormonal levels
result in▪ ↓ability to concentrate urine
▪ Altered excretion of water, sodium, potassium, and acid
▪ Prostate enlargement

Question 19

medications affecting urination

Answer 19

Nephrotoxic (capable of causing kidney damage)
❖ Diuretics: ↑ vol., frequency, urge incontinence
❖ Cholinergics stimulate bladder contraction
❖ Analgesics and sedatives impair CNS to control urination
❖ Anticoagulants may cause hematuria
❖ Some medications change the color of urine:
❖ Phenazopyridine (Pyridium): a urinary tract analgesic commonly used for UTI symptoms turns urine orange
❖ Amitriptyline and B-complex vit can turn urine green blue
❖ Levodopa for Parkinson can turn urine brown or black

Question 20

urinary history assessment**(PAHML - the palm of my urine)

Answer 20

1. Urinary Pattern (frequency, urgency, drippling, incontinence, inability to empty bladder)
2. Appearance of Urine – color, odor, and clarity
3. History of urinary problem- UTI, surgery, pain
4. Current medications (many medications are nephrotoxic)
5. Lifestyle Questions: how much fluid a day, smoker, caffeinated
   drinks

Question 21

urinary assessment

Answer 21

Person should be in dorsal recumbent position
Inspect:❖ Skin and mucosal membrane
❖ Skin turgor, oral mucosa for hydration status
❖ Perineum for incontinence related skin maceration
❖ Observe urethral orifice for discharge, lesions, inflammation
❖ Inspect urine output for color, clarity, odor
Palpate:❖ Normal bladder is positioned in the pelvic cavity around the symphysis pubis; not palpable when empty
❖ Bladder distended (palpable and well above symphysis pubis)Percuss:
❖ Costovertebral angle tenderness
❖ Formed by junction of 12th rib and the spine
❖ Tenderness may indicate pyelonephritis
Auscultate:❖ May hear renal artery bruit- turbulent blood flow through a narrowed artery

Question 22

pathological urinary disorders (don’t need to know this)

Answer 22

❖ UTI
➢ Catheter-associated UTIs (CAUTI)
➢ Cystitis
➢ Pyelonephritis (infection of ureters and kidneys)
➢ Urethritis
❖ Benign Prostate Hypertrophy
(BPH)
➢ leads to incomplete emptying
and frequent urination
❖ Nocturnal enuresis
❖ Incontinence
❖ Renal calculi

Question 23

alterations in urinary elimination: UTI

Answer 23

Lower UTI
S/S▪ Dysuria, frequency, urgency, burning, pyuria (white blood cells in urine)
▪ Older adults may initially p/w change in mental status ▪ May or may not have sx
Lab Urine analysis▪ + nitrite (nitrite forming bacteria)▪ ↑ in Leukocyte esterase Urine Cx▪ E. coli most common
**If untreated, infection can progress up to kidneys
Upper UTI/ Pyelonephritis
S/S
▪ Fever, chills, flank pain, n/v,
malaise, hematuria
▪ Urosepsis
Diagnostic
▪ UA C&S
▪ Blood cx
▪ CBC, lactate acid
▪ Creatinine and BUN level for AKI

Question 24

collecting urine

Answer 24

Supplies:
• Sterile collection container
• Clamp
• Syringe
• Anti-septic swap
• Non-sterile gloves
Do not collect from foley bag
• Observe sterile technique
while collecting specimen

Question 25

24 hour collection (to measure what? and detect what?)

Answer 25

Purpose:To detect abnormal renal disorders such as diabetic nephropathy, nephrotic syndrome, nephrolithiasis (kidney stone) ❖ UOP from a 24 hr period collected to see how much creatinine clears through the kidneys. ❖ Also done to measure amount of protein, hormones, minerals, and other chemical compounds in the urine

Question 26

specimen collection***

Answer 26

• Ensure patient and all caregivers understand the importance of collecting all urine during the 24 hrs• Post sign in bathroom with start and end time and date of collection• ***Have patient empty bladder and discard which will be the ”start time”•*** Put “ALL” UOP in 24hrs in the urine container (usually on ice)• At the end of 24 hrs, have pt void again and place urine in container. **If any urine gets discarded

Question 27

bladder scanner***

Answer 27

Used to measure urinary retention or post void residual (PVR) ❖Bladder distention ❖May result from BPH (prostate problem) prostate CA, neurogenic bladder, after long period of foley catheter use ❖S/S include frequent voids with

Question 28

uti prevention****

Answer 28

❖ Practice good personal hygiene ❖ **Always wipe from front to back ❖ Promote fluid intake (2000 to 2500mL/day) ❖ Empty bladder completely when you feel the urge (urinary stasis promotes bacterial growth) ❖ Wear moisture wicking underwear ❖ During sexual intercourse, use vaginal lubricants if needed (decreases vaginal friction and potential tear) ❖ Empty bladder after intercourse (flushes out bacteria that may have entered urethra) ❖ Change sanitary pads and tampons frequently during menstruation

Question 29

CAUTI****

Answer 29

***80% of nosocomial UTI’s caused by urinary catheters (usually undetected and patient becomes septic) ❖Increases hospital stay, morbidity and mortality in patients ****Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems ***Bacteria with biofilms resistant to antimicrobials and host defenses ❖CAUTI rates often a benchmark measure in the National Healthcare Quality and Disparities Reports (NHQDR)

Question 30

CAUTI prevention***(catheters) (CDC guidelines)

Answer 30

❖Insert catheters only for appropriate indications consider external devices ***Remove catheter as soon as possible ***Normal and expected to feel burning sensation initially after catheter removal ❖Ensure sterile technique throughout insertion procedure ❖Proper hand hygiene and Standard Precautions

Question 31

Nursing Management of Ileocdonuit (I guess this means stoma?)****(and monitor what?)

Answer 31

Inspect stoma regularly ❖Monitor UOP and PO intake for adequate hydration ❖Mucous threads in urine is normal since urinary diversion is created using intestinal tract ❖Encourage patient participation in care of stoma ❖Start education on care of urinary device early ➢ Assess coping and readiness for teaching

Question 32

urinary incontenence (TOILETED) and the last weird one

Answer 32

Inability to control urine flow Mnemonic for contributing factors: TOILETED ▪ T: Thin and dry vaginal and urethral epithelium ▪ O: Obstruction ▪ I: Infection ▪ L: Limited Mobility ▪ E: Emotional or psychological problems ▪ T: Therapeutic Medications ▪ E: Endocrine disorders (Diabetes Insipidus) ▪ D: Delirium

Question 33

types of urinary incontenence

Answer 33

Transient ❖ Appears suddenly and last ≤ 6mths ❖ Etiologies: diuretics, acute delirium, acute illness Stress ❖ Involuntary loss of urine r/t ↑ intrabdominal pressure e.g. coughing, sneezing, laughing, after childbirth Overflow ❖ Involuntary urine loss r/t overdistention of bladder Mixed ❖ Urine loss with features of ≥ 2 types of incontinence Functional ❖ As a result of inability to reach toilet r/t physical, environmental barriers, memory loss, neurological Total ❖ Continuous and unpredictable urine loss r/t anatomical abnormality

Question 34

Nursing Management: Incontinence***

Answer 34

Nursing Management: Incontinence ❖Bladder training according to a timetable rather than urge to void ❖****Pelvic floor muscle training: Kegel ❖Regulate fluid intake during evening hours and encourage fluids between 6 am and 6 pm ❖Avoid ETOH and caffeinated beverages ❖Pharmacologic dependent on type of incontinence ❖Keep perineal area clean and dry (change incontinent pads when wet) ❖Take diuretics early in the day ❖Lose weight for BMI >30

Question 35

Stomach (store the chyme in the stomach, and use the sphincter) (GI Tract Role and Function)

Answer 35

❖ Stores food during eating, secretes digestive enzymes to partially break down food (chyme) ❖ Pyloric sphincter controls movement of chyme into small intestine

Question 36

Bowel Elimination Control

Answer 36

Bowel Elimination Control ❖ Controlled by the autonomic nervous system ❖ Parasympathetic nervous system ➢ Rest and digest ➢ Stimulates intestinal peristalsis ❖ Internal anal sphincter is under involuntary control ❖ External anal sphincter under voluntary control ❖ Valsalva maneuver: bearing down technique during defecation→ ↑ intra-abdominal and thoracic pressure → ↓blood flow to atria and ventricles → Cardiac output → bradycardia and syncope

Question 37

Assessment of GI System*****

Answer 37

Assessment of GI System Assessment order: Inspect, auscultate, percuss, palpate Inspect: ❖ Moist pink lips, mucosal membrane, oral hygiene ❖ Cough, gag, dysphagia ❖ Contour, lesions, for visible peristaltic waves ❖ Anal fissures, hemorrhoids Auscultate: ❖ Bowel sounds in all quadrants Palpation: ❖ Use warm hands ❖ Palpate for tender areas Percuss: ❖ General tympany is normal

Question 38

Constipation: (alternation in bowel elimination) (causes)

Answer 38

❖ Common: Narcotics/opioids ➢ Other meds: antihistamine, antiHTN, diuretics, Fe and Ca supplements ❖ Immobility, prolonged bedrest, lack of exercise ❖ Irregular bowel habits, ignoring urge to defecate ❖ Post-op → paralytic ileus ❖ Chronic illness ❖ Diet: Low fiber diet, high in animal fat- meat, dairy, eggs ❖ Inadequate fluid intake ❖ Older population: Loss of abdominal elasticity, slowed peristalsis, reduced intestinal mucus secretion, cognition impairment

Question 39

preventing and treating constipation***(how much fluid and fiber)

Answer 39

Dietary: High fiber with adequate fluids ➢20-35 g fiber/day ➢Fluids 1.8 to 2.5L /day ➢Avoid caffeinated drinks ❖ Do not delay urge to defecate (Results in hard stool, decrease urge) ***Exercise ❖ Medication: stool softeners, laxatives, enemas, suppositories, PO narcan, digital dis-impaction

Question 40

fecal impaction*****

Answer 40

Prolonged retention of fecal material forming hard mass in rectum: Signs and Symptoms: ❖ Constipation ❖ Bloating ❖ Bowel obstruction on KUB ❖ Involuntary leaking of liquid stool ❖ Nausea ❖ Excessive flatulence Treatment for constipation/fecal impaction: ❖ Laxatives, Suppository and enemas ❖ Manual Removal ❖ Medications: narcan, cholinergics

Question 41

preventing and Treating Diarrhea***

Answer 41

Definition of diarrhea is ≥ 3 loose stools in a 24hr period Etiologies: Excessive use of laxatives Certain antibiotics Infectious – Clostridium Difficile ***Initiate enteric contact isolation and send stool sample for C-diff Complications: Dehydration Electrolyte abnormalities Moisture associated skin damage (Incontinence Associated dermatitis

Question 42

Infectious Diarrhea: Clostridium Difficile****

Answer 42

Etiology: ▪ Antibiotics (abx) kill off normal flora increasing susceptibility to pathogenic organisms ▪ C-diff spores can survive many months on objects- commodes, bedside tables, thermometers, etc. ▪ Must use soap and water for hand hygiene (Etoh base not effective) ▪ Enteric isolation in private room ▪ Do not give anti-diarrheals as the diarrhea is infectious ▪ C. diff is treated with combo abx-Metronidazole and Vancomycin ▪ Fecal transplantation ▪ Test all patients for C-diff if having ≥ 3 loose stools in 24 hr period ▪ Avoid giving unnecessary broad spectrum abx

Question 43

Nursing Management for Diarrhea***

Answer 43

Nursing Management for Diarrhea ❖Hydrate! ❖Antidiarrheal agents only if not infectious diarrhea ❖Clear liquid diet or as tolerated ❖BRAT diet ➢ Banana ➢ Rice ➢ Applesauce ➢ Toast ❖Reduce fiber ❖Limit caffeine ❖Yogurt and probiotics

Question 44

Bowel Diversion Device****(stoma, diseases that would cause you to need one)

Answer 44

Indication: ❖ Severe IBS ❖ Severe Crohn’s ❖ Bowel perforation ❖ Colon or rectal CA ❖ Abd trauma *May be permanent or temporary

Question 45

bowel diversion - Ileostomy****(illeana was a fluid dancer)

Answer 45

End of ileum (small intestine) brought through opening to abd wall to form a stoma. liquid to semi-liquid

Question 46

acute kidney injury***▪ Intrarenal-factors (dying from the inside out - intra)

Answer 46

causing direct damage to kidneys/ATN (acute tubular necrosis)

Question 47

acute kidney injury***Postrenal-factors - this is just obstruction

Answer 47

causing mechanical obstruction to flow of urine ▪ Potentially reversible ▪ Older adults more vulnerable

Question 48

Colostomy

Answer 48

Colostomy: One end of large intestine is brought out onto abdominal wall by the construction of a stoma

Question 49

****Characteristics of stoma

Answer 49

➢ pink/red normal (pale-anemia, maroon/purple-ischemia) ➢ Edema (severe d/t obstruction, allergic rxn, gastroenteritis) ➢ Bleeding (small amount normal d/t high vascularity

Question 50

****stoma - Characteristics of drainage/stool - change how often?

Answer 50

depends on new or existing ostomy and location of ostomy ❖ Note amount and frequency ❖ Change ostomy bag every 3 days or policy (more frequent if needed) ❖ Physical and Psychological support

Question 51

what are the leading causes of CKD? (chronic kidney disease) think kidneys...(Just 2)

Answer 51

DM and HTN (high blood pressure) are the leading causes of CKD

Question 52

bowel diversion (stoma) ascending***(c in ascend is for c for colostomy, c for semi)

Answer 52

colostomy - large intestine. perforating diverticulum in lower colon. semi-liquid

Question 53

bowel diversion (stoma) - transverse (sideways can go either way, so...)

Answer 53

colostomy - large intestine. perforating diverticulum in lower colon. semi-liquid to semiformed, possibly increased.

Question 54

bowel diversion (stoma) - sigmoid (freud is large and formed)

Answer 54

colostomy - large intestine. formed.

Question 55

Foods high in what impede bacterial growth?

Answer 55

Foods high in Vit C., prevents UTIs

Question 56

how often to Perform foley care/peri care?

Answer 56

every shift

Question 57

CAUTI consideration - devices

Answer 57

Consider external urinary collection devices

Question 58

CAUTI - maintain open or closed drainage system?

Answer 58

closed

Question 59

CAUTI - where to keep foley bag?

Answer 59

Maintain unobstructed urine flow - keep foley bag below level of bladder

Question 60

GI tract - small intestines (parts of the small intestine, functions)

Answer 60

❖ Approximately 20ft x 1in ❖ 3 parts: Duodenum, ileum, jejunum ❖ For digestion and absorption of nutrients ❖ Secretes enzymes to digest proteins and carbohydrates ❖ Digestive juices from liver and pancreases enter the duodenum for digestion

Question 61

GI tract - large intestines (how long, how much water absorbed)

Answer 61

❖ Approx. 5 ft x 1-3” ❖ For absorption of water and formation of feces ❖ 800-1000mL water gets absorbed daily ❖ Peristalsis move intestines to push waste into rectum

Question 62

GI tract - rectum

Answer 62

❖ Holds stool until evacuation ❖ 5”x1” (1” of that is the anal canal)

Question 63

is minor bleeding with stoma normal?

Answer 63

yes

Question 64

is caffeine good for constipation?

Answer 64

no

Question 65

groups at risk for fecal impaction

Answer 65

Population at risk: ❖ Immobile patients – e.g. spinal cord injury and older adults ❖ Post-op (opioid use, decrease activity, n/v, low appetite)

Question 66

Infectious – Clostridium Difficile***what to do if you suspect it?

Answer 66

Initiate enteric contact isolation and send stool sample for C-diff

Question 67

3 major causes of AKI (before, middle, after)

Answer 67

pre-renal, intranrenal, and post-renal factors

Question 68

prerenal factors that cause AKI (I HADD prerenal factors)

Answer 68

dehydration, diarrhea, heart failure, acute blood loss

Question 69

intrarerenal factors that cause AKI (vancomyicin intra, within, the kidneys)

Answer 69

exposure to nephrotoxins, (vancomyocin it's excreted through the kidneys and can damage them)

Question 70

post-renal factors that cause AKI (post with stone) - post is literally physical - after your kidneys

Answer 70

kidney stone, back up in kidneys

Question 71

any pain in 12th rib is caused by...

Answer 71

pylonephritis

Question 72

if older patient is acting confused, it could be a...

Answer 72

UTI

Question 73

use a bladder scanner if the patient has...

Answer 73

not voided during your shift. if scanner shows around 300 ml, it's the cutoff