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Introduction To Nursing > USCR Elimination > Flashcards

Flashcards in USCR Elimination Deck (56):
1

What is elimination?

Excretion of waste products by the skin, kidneys and intestines.

2

What to look for in an assessment for elimination?

Client’s Health History
Interview (BCF data: subjective)

Physical Examination
(objective data)

Diagnostic and laboratory studies

3

Urinary elimination depends on what 4 urinary tract organs?

Kidneys (filter urine)
Ureters
Bladder
Urethra

4

factors influencing urination?

Age
Psychosocial factors*
Fluid and food intake
Medications
Muscle tone and activity
Pathological conditions
Surgical and diagnostic studies

5

What to look for in bladder assessment?

empty bladder
distended bladder
urinary retention
retention with overflow
incontinence

6

What is a distended bladder?

full, palpable bladder

7

What is urinary retention?

inability to void or empty bladder completely

8

what is retention with overflow?

small amount of urine escapes bladder despite retention

9

what is incontinence?

involuntary urination)

(symptom of something else going on)can be due to physiological, neurological disorders

10

normal frequency of urine elimination?

5-7 times/day

Normal urine output= 1500-1600 mL/24 hours; about 500 mL/4 hours; at least 30 mL/hr

11

What is dysuria?

painful or difficult urination (UTI is most common cause of dysuria)

12

what is urgency?

increased urge to void

13

what is hematuria?

blood in urine

14

what is nocturia?

excessive urination during the night

15

what is hesitancy?

inability to induce urinary flow

16

what is dribbling?

inability of urinary sphincter to contract completely resulting in drops of urine

17

what is polyuria?

increased urination (>3L of fluid in 24hr) usually seen in diabetes mellitus water follows glucose out during filtration, too much glucose to reabsorb=incr water loss=incr urine); or diabetes insipidus (disorder of urine concentration).

18

What to look for in assessment of urine?

colour (straw colour --> tea colour)
clarity (clear --> cloudy --> turbid)
odour (no smell --> strong nitrate)
quantity (drips --> 1L+)

19

Urine test?

Sterile container for C&S (culture & sensitivity)
Culture to identify microorganism
Sensitivity to identify antimicrobial/antibiotic the microorganism is sensitive to.

dipstick

20

action demand for urine?

Maintain normal urinary
elimination by:

assuming normal positioning for urination,
e.g. standing for men
squatting for women


Taking time to void
voiding when the urge arises (don’t ignore it).
maintaining privacy if required
practicing proper hygiene (wipe front to back) to prevent UTI.
drinking at least 2 L of fluid to prevent UTI and ensure quantity of urine.
voiding immediately after sexual intercourse to prevent UTI.

21

what is bowel elimination?

Elimination of the waste products of digestion from the body is essential to health

22

factors affecting bowel elimination?

age
diet
fluid intake
activity
psychological factors
defecation habits
medication
diagnostic procedures
anaesthesia and surgery
pathological conditions
pain
Food and fluid intake
Exercise
Laxatives

23

what is constipation?

<3 stools/week

24

what is impaction?

unrelieved constipation

25

what is diarrhea?

increased frequency of defecation
risk of dehydration

26

what is fecal incontinence?

large amount of loose, water stools (IBS) chronically loosing too much fluid

27

what is flatulence?

passing gas

28

what are hemorrhoids?

dilated, engorged veins in lining of rectum

can cause discomfort and pain + bleeding

29

What to look for in abdominal assessment?

Look (slightly convex, distended, smooth)

Listen (auscultate)

Feel (palpate for masses or tender areas)


Before doing physical assessment, make sure to have a detailed health history; that is, the patient’s assessment of their normal frequency, stool characteristics (formed, hard, liquid), pain (location, type) and self-care habits (fiber, fluids, laxatives, exercise).

30

abdominal assessment?

Abdomen:
distended
soft/hard
pain
sounds

Abdominal quadrants
Right upper
Left upper
Right lower
Left lower

31

bowel sounds?

Are heard in all quadrants
Usually are high pitched
Occur irregularly 5-35 times per minute


**Bowel sounds are auscultated before palpation of abdomen. Can anybody tell me why that is?


when you start palpating, you are stimulating the bowel and you will get a false auscultation reading

32

stool assessment?

color, consistency, shape, odor, frequency

3x/week-3x/day is normal range to go

melenia: black tarry stool = bleeding in upper intestinal track
grey/white stool: obstruction of bowel tract

33

stool laboratory tests?

ova & parasites


Culture will produce many bacteria; labs looking for those that may cause pathological conditions.
Sensitivity of pathogen to specific antibiotics.

34

Test for occult blood?

Hemoccult: test specifically for occult or hidden blood in the stools, which is the result of GI bleeding that is not visible to the naked eye.

35

what is documented in client chart?

Last BM recorded
Medications taken for BM
Enema given

36

action demand for dedication?

Promote normal defecation by:

taking time to defecate
responding to the urge to defecate
eating a diet high in fibre
drinking at least 2000 mL fluid/day
exercising daily
avoiding the regular use of laxatives

37

functions of the skin?

Protects from injury and passage of micro organisms

Regulates body temperature

Secretes sebum – softens & lubricates skin

Transmits sensations – pain, temperature, touch & pressure

Produces vitamin D

38


FACTORS AFFECTING SKIN INTEGRITY?

immobility (pressure sores)
inadequate nutrition, hydration
fecal and urinary incontinence
decreased mental status
diminished sensation
excessive body heat
advanced age

39

Skin Assessment?

colour
turgor
intact
cleanliness/odour
texture
temperature (warm/cold)
moisture
edema

40

Skin Assessment?

changes in skin
e.g. colour
texture
edema
itchiness
any lesions
changes in lesions or moles

41

Self Care Practices for sun?

How much time in the sun?
Use of sun screen?
Use of sun lamps?
Wears hat in sun?
Hygiene practices at home:
-frequency of bath
-type of soap
-moisturizer

42

Action demand for skin?

Maintain elimination processes through good skin integrity by:

practicing proper hygiene, e.g. don’t use rough soaps, moderate water temperature.
eating a well balanced diet, e.g. protein builds tissues.
doing regular exercise.
drinking adequate fluid
intake (2 L / day).

43

action demand for sun protection?

Protect the skin from sun and cold:
SUN
sunscreen at least 15 SPF and containing both UVA and UVB protection
wear hat in the sun
cover arms and legs
stay indoors when sun is strongest

44

action demand for cold weather?

wear warm clothing
cover face, ears
prevent metal from touching skin

45

what is menstruation?

A discharge of blood, secretions, and tissue debris from the shedding of the endometrium from the non-pregnant uterus that recurs at approximately monthly intervals.

46

what to look for in menstruation assessment?

Duration of period = average 3-5 days

Regular periods = average 28 days
intervals

Menarche = first menstruation (onset)

Menopause = period which marks the permanent cessation of menstrual activity.

47

menarche?

first menstruation (onset)

48

menopause?

period which marks the permanent cessation of menstrual activity

49

menstruation assessment?

colour = bright red --> brown

amount = spotting --> heavy

odour = slight smell

50

what is amenorrhea?

absence or suppression of menstruation (including pregnancy, lactation, & menopause or illness/ pathology)

51

what is dysmenorrhea?

pain associated with menstruation

52

menorrhagia?

abnormally heavy or prolonged bleeding, interfering with normal ADL (soaking more than 1 sanitary pad per hour for several hours); may show signs of anemia

53

metrorrhagia?

bleeding between periods

54

self care practices for menstruation?

Hygiene
Comfort measures
Exercise
Sex when menstruating

55

products that can cause vaginal infection?

Use of: major causes of infections
deodorized tampons, pads
douches
vaginal sprays
bubble bath
super-absorbent tampons (Toxic Shock Syndrome)

56

toxic shock syndrome?

S & S: A sudden high fever.
Low blood pressure (hypotension)
Vomiting or diarrhea.
A rash resembling a sunburn, particularly on your palms and soles.
Confusion.
Muscle aches.

can cause death!