GU assessment Flashcards
(85 cards)
1
Q
3 this we do for a GI (gastrointestinal assessment)
A
- inspect
- auscultation (listen)
- palpate
*remember if we hear something with our stethoscope we may not palpate because it could possibly rupture something
2
Q
How many quadrants does the abdomen have?
A
4 quadrants (RLQ, RUQ, LUQ, LLQ)
3
Q
Right Upper Quadrant (RUQ)
A
contains liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portion of right kidney, hepatic flexure of colon, portions of ascending and transverse colon
4
Q
Right Lower Quadrant (RLQ)
A
lower pole of right kidney, cecum and appendix, portion of ascending colon, bladder (if distended), right ovary and salpinx, right spermatic cord, right ureter
5
Q
Left Upper Quadrant (LUQ)
A
left lobe of liver, spleen, stomach, body of pancreas, left adrenal gland, portion of left kidney, splenic flexure of colon, portions of transverse and descending colon
6
Q
Left Lower Quadrant (LLQ)
A
lower pole of left kidney, sigmoid colon, portion of descending colon, bladder (if distended), left ovary and salpinx, uterus (if enlarged), left spermatic cord, left ureter
7
Q
Inspection for GI
A
- inspect for abdominal color, structure of abdomen, abdominal contour, symmetry, pulsations, and abdominal movement
- inspect for any scars, lesions, or stretch marks
- inspect umbilicus for position, shape, color and signs of inflammation, any discharge or protruding masses
8
Q
Auscultation (listen)
A
-Auscultate the abdomen by listening with the diaphragm of the stethoscope to the bowel sounds in all 4 quadrants (start with the RLQ then go to RUQ, LUQ, then LLQ)
*RLQ has the most activity
(if don’t hear any bowel sounds must listen in each quadrant for a full minute for a total of 5 minutes to say there is absence of bowel sounds)
9
Q
4 types of bowel sounds
A
hyperactive, hypoactive, absent, normoactive
10
Q
Hyperactive bowel sounds
A
may be loud and higher pitched and rushing
(could be from infection or diarrhea)
*more than 30 sounds
11
Q
Hypoactive bowel sounds
A
slow and sluggish (abdominal surgery, bowel obstruction)
*less than 5
12
Q
absent bowel sounds
A
listen over EACH quadrant for a minimum 3-5 minutes (1 minute per quadrant total of 5 minutes) before declaring (paralytic ileus=obstruction of the intestine due to paralysis of the intestinal muscle)
13
Q
normoactive bowel sounds
A
irregular, gurgling sounds that occur from 5 to 30 times a minute
14
Q
peristalsis
A
movement of the muscles
15
Q
flatulence
A
gas
16
Q
defecation
A
discharge of feces
17
Q
nausea
A
a sensation including urge to vomit
18
Q
vomiting
A
emesis (forcefully expelling the stomach’s content out of the mouth)
19
Q
palpation for GI
A
- determines organ size, placement muscle tone, masses, and presence of fluid
- painful areas should be palpated last
- contraindicated for clients with appendicitis, dissecting aortic aneurysm, polysystic kidney disease, or an organ transplant
- light palpation in each quadrant to detect areas of tenderness
- palm of hand with pads of fingers extended
20
Q
GU
A
genitourinary (kidneys, ureters, bladder, urethra)
21
Q
bladder
A
normal capacity is 600-1,000mL
sense the desire to urinate (VOID) q2-q4 (every 2-4 hours) about 200mL
*30mL=1oz
22
Q
assessment for GU
A
daily voiding patterns
volume
distention
flank pain (located in the back where kidney is)
skin rashes, blisters, irritations, breakdown
LMP? (last menstrual period for females)
23
Q
assessment of urine
A
color: -yellow/amber (normal), straw, pale -dark yellow/amber, red (could see this for someone who doesn't drink a lot of water) clarity: -transparent, clear -cloudy, sediment Odor: -ammonia (normal smell) -fruity (might smell fruity for someone who has diabetes)
*get an order if urine is cloudy
24
Q
output
A
average daily urine output= 1500mL per day
less than 30mL/hour could be a concern
*if someone is only voiding 720mL/day might be a sign of kidney function
25
what is the adequate fluid intake?
8 glasses per day unless contraindicated
26
Essential skills for abdominal assessment
- inspect abdomen for symmetry, color lesions, scars, and abdominal movement
- auscultate bowel sounds in all 4 quadrants
- palpate abdomen in all 4 quadrants
- assess GI & GU patterns and characteristics
27
gastrointestinal (patient specific norms)
abdomen is soft and non-tender w/o distention
bowel sounds active X4
tolerating prescribed diet w/o nausea and vomiting
bowel movements w/in own normal patterns and consistency (no incontinence)
28
genitourinary (patient specific norms)
able to empty bladder w/o difficulty, frequency, or urgency or dysuria
urine is clear and yellow/amber in color
no incontinence (foley? I/O?)
29
Urethra size for males and females
```
men= 8 inches
women= 1.5-2.5 inches
```
30
5 kidney functions
1. filters blood in removing wastes to create urine
2. regulates body fluids and electrolyte balance
3. regulates blood pressure
4. involved in production of RBCs (red blood cells)
5. synthesizing vitamin D
31
act of urination (voiding, micturition)
- stretch of bladder walls signals the micturition center in sacral spinal cord
- impulses from the micturition center in brain (respond to or ignore this urge) makes urination under VOLUNTARY control
- when a person is ready to void external sphincter relaxes, stimulates detrusor muscle to contract
- bladder empties
32
Ureter
urine will fill in the ureter go to void muscle contracts (valve will close off) so urine does not go back up the ureter to the kidney (can cause bacteria to grow)
"reflux" is anything that goes back up the ureter
33
nocturia
is voiding at night or during normal sleep time
can be expressed in numbers of times person gets out of bed to void
example: nocturia x 4
can be descried as frequency (may see in pregnant women, increase fluid intake, or from UTIs)
34
dysuria
refers to voiding that is either painful or difficult
can bed caused by a stricture, which a portion of the urethra is decreased in diameter, a UTI, or an injury to the bladder or urethra
(urinary tract inflammation, infection, injury)
35
diuresis or polyuria
production of abnormally large amounts of urine by the kidneys (often several liters more than the patients daily output)
increase in urine production
36
oliguria
small (scanty) amount of urine
decrease fluid intake
dehydration
presence of hypotension, shock, or heart failure
history of kidney disease
presence of elevated BUN (blood urea nitrogen) and serum creatinine
edema
37
anuria
no urine (no production/formation of urine)
38
caffeine
bladder irritant (increases urine causes contraction more urination)
39
urinary retention
accumulation of urine due to the inability of the bladder to empty
feeling of pressure, void small amounts
(don't have ability to empty bladder (retaining)--at risk for "reflux" with the valve--urine goes back into kidney)
40
residual urine
urine that remains in the bladder after voiding due to swelling or bruising of the tissue around the urethra, decreased sensitivity to fluid pressure, and decreased sensation of bladder filling
100 mL urine remaining in bladder
(*urine is acidic, if bladder is not being emptied bladder becomes alkaline, where bacteria can grow)
*urine acidic protects against bacteria growth--->if retained becomes alkaline--->risk for infection*
41
urinary frequency
void more than usual (every hour)
frequency is determined when voiding occurs more often than the individuals typical pattern
conditions such as UTI, pregnancy, stress can cause frequent urgency to urinate or small quantities (500-100mL)
*elderly are at risk for void frequency
42
urinary stress incontinence
involuntary void (involuntary leakage of urine)- can happen when someone coughs or sneezes and have leakage and become wet
*risk for skin breakdown because of wetness
43
urinary urgency
void immediately (sudden strong desire to urinate)
44
urinary hesitancy
is a delay and difficulty in initiating micturition or the stream of urine and is often associated with dysuria
*difficulty with men who have a large prostate
45
medical interventions affecting urination
surgical procedures and medications
46
surgical procedures
restriction of fluid intake lowers urine output
stress causes fluid retention
anesthesia- decreases all body systems
localized trauma, childbirth
47
medications
may cause urinary retention, incontinence, or urgency
some change of the color of urine
(example: medication Pyridium= turns urine orange)
*pyridium helps with spasms of bladder
48
disease control affecting urination
prerenal (decrease blood flow to urine)
renal (tissue disease)
postrenal (obstruction)-in ureter (tumor, narrowing, etc)
diabetes mellitus and neuromuscular disease such as multiple sclerosis (nerve function changes)-some type of charge in nerves) (spinal cord, brain, or nerves)
benign prostatic hyperslasia cognitive impairments (alzheimer's) brain change, spinal corn, brain, nerves , lose sensory nerve response
conditions that make it difficult to reach and use toilet facilities (not able to get to bathroom)
49
BPH Benign prostatic hyperplasia
prostate becomes enlarged increase cell growth it blocks urethra and can cause retention and unable to start stream of urine
50
UTI (urinary tract infection)
invasion of the bladder, ureter, or kidney by microorganisms (all parts of the urinary system)
persistent urge to urinate (urgency)
burning sensation during urination
cloudy, red, or strong-smelling urine
pelvic or rectal pain
admission of antibiotics if infection is caused by bacterium
51
Pyelonephritis
kidney infection
52
ureteritis
infection of ureter
53
cystitis
bladder infection
54
urethritis
urethra infection
55
bacteriuria
bacteria in urine most commonly cause by E. Coli (in intestines) can lead to bacteremia/urosepsis
56
bacteremia/urosepsis
bacteria in bloodstream (throughout whole body much more severe)
* most common: E. Coli bacteria
* urinary tract is sterile
57
UTI signs and symptoms (S&S)
dysuria- painful urination (could possibly see blood)
hematuria- blood in the urine
frequency and urgency
cloudy (pyruia=puss in urine) *normal urine is clear*
foul odor
58
UTI S&S in elderly
change in behavior
confusion
incontinence
59
Renal failure End-stage Renal Disease (ERSD)
renal failure is the term used when the kidneys cease to produce urine. Heart and circulatory disorders, such as heart failure, shock, or hypertension affect blood flow to the kidneys interfering with urine production
someones kidney is not properly functioning to create urine (dialysis) kindeys are for filtering waters, regulating BP, balance, etc
essentially is like having an artificial kidney
60
AV Fistula- Dialysis
are they getting dialysis?
do they have something planted in skin
(vibrate or swishing noise?)
planted under the skin dialysis is working as a kidney
61
Ileal conduit
urinary diversion is rerouting the urine create an artificial "stoma" where urine can exit (on wall of abdomen) at risk for skin breakdown
62
nephrostomy tube
surgically implanted artificial ureter/bladder sticks out of persons body (maybe some type of tumor or trauma)
63
assessment GU
```
daily voiding patterns?
volume (large or small amounts)
symptoms
skin rashes, blisters, irritation, breakdown
hygiene
LMP for females
```
64
distended bladder
rises above symphysis pubis
65
skin and mucosal membrane hydration
turgor, weight loss
66
kidney flank pain
where kidney is located
67
costovertebral angle
area in flank where they will have pain
68
Calculi
"kidney stones" formation of calculi w/in the calyx of the kidney
mild to severe pain in the side and pack, in the abdomen, or during urination
cloudy or foul smelling urine
nausea and vomiting
crystals formed from concentrated urine (made of uric acid and calcium) it can travel to ureter and can be in bladder (crystals are sharp edges)
*get an order to strain urine and catch the stones
69
average daily urine output
1500mL/day
less than 30mL/hr is a concern
(remember 30mL=1oz)
70
urine measure device (Hat)
can measure your urine output
71
urinals
positioning is important
(men may need to stand to void)
collects urine
72
urine testing
urinalysis (U/A): sending urine to the lab (test acid, protein, glucose, concentration, etc)
Culture and sensitivity (C&S): culture find bacteria in urine; sensitivity check and see what antibiotics that would take care of bacteria
Specimen collection (midstream/clean voided/clean catch): clean perineal 3 times (left, right, center) start stream of urine in toilet, then catch urine in cup and fill up about half way)
73
24 hour urine collection
collect urine for 24 TRUE hours, it tests steroids, kidney function, etc
has to stay in refrigerator if at home; keeps it preserved
1st urine gets discarded in toilet then start collecting for a full 24 hours
*if forget and void in toilet MUST start over, it HAS to be a full 24 hour
(start at 7am and go until 7am the next day)
74
GFR (glomerular filtration rate)
speed of kidney filtration; how fast kidney filters, how well its working (N=90mL/min)
*if GFR is less than 30mL/min could be some type of kidney function problem
BUN (blood urea nitrogen): 5-25 (norm)
Creatinine: 0.5-1.5 (norm)
if BUN/Creatinine increase worse kidney function; decrease BUN fluid overload
75
nursing interventions (toileting)
```
scheduled toileting-elderly
potty training- bed wetting
keep close to the BR (bathroom)
adequate lighting
fall risk
comfortable clothing (easy on and off)
sit vs stand
allow time, relaxation, and privacy
sound of running water can help someone void
```
(hygiene- prevent infection)
maintain skin integrity
barrier creams
adequate fluid intake= 8 glasses/day unless contraindicated
76
urinary drainage system
don't put it in for convenience need a doctors order
assess urine in the tube*
compare whats in the tube to what is in the bag (color may vary if it has been sitting in the bag for a while)
assess for color, clarity, etc
77
urinary catheters (intermittend (straight) vs. Indwelling)
intermittent (straight): insert, drain, take it out (may use for the immediate relief)
indwelling: keeping it in the bladder
* at more of a risk with indwelling catheters
* need a doctors order for both
* sterile
78
intermittent (straight catheter)
assess residual
obtain sterile specimen (if cant get patient to void)
immediate relief of distention (if someone has discomfort)
79
indwelling catheter (aka foley)
stat lock-make sure its secure so it doesn't fall out or get pulled out (can cause damage to urethra)
*sterile
80
catheterization (sterile technique)
lubricate 1-2 inches for women
lubricate 5-7 inches for men (because urethra is longer)
betadine swab (3 times left, right, center, 1 swab per each)
ask to bear down when insert catheter
after urine appears, advance another 1-2 inches
(evidence based practice says take it all the way to bifurcation)
Coude catheter: doctors orders; NEVER force it for a man (anytime pain or discomfort, if complaining of pain contact doctor unless they already have a urologist consultant)
81
safety
identify patients with latex allergy
identify patients with allergies to povidone-iodine (betadine)
provide alternatives such as chlorhexidine
(keep back below patient, urine in drainage bag not on the floor but below the bladder)
empty before ambulate or going somewhere (e.g tests, PT, etc)
82
catheterization safety
closed drainage system
allow free drainage of urine by gravity
keep drainage bag lower than bladder (to prevent urinary reflux)
empty badder before ambulation
*perineal care (soap and water) 3 times a day
83
discontinue catheter
after taking out catheter patient void within 4 hours (assess patient if dont void; bladder scan)
84
psychosocial
```
impaired body image
alteration in self concept, self esteem
sexuality impairment
gender identify
culture considerations
provides information, counseling referrals
Holistic needs (mind body spirit)
```
85
within defined limits GU UPMC cerner documentation
able to empty bladder without difficulty, frequency, urgency or dysuria (no incontinence)
urine is clear and yellow/amber in color
female-no complaint or evidence of breast tenderness or masses. No complaints or evidence of vaginal drainage itching swelling or lesions
(should do self breast exams at least once a month)
males: no complaints or evidence of lesions/ulcers, inflammation or drainage of the penis or scrotal pain/edema
