Scientific Knowledge Base Urinary 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. Kidney The 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. Ureters A ureter is attached to each kidney pelvis and carries urinary wastes to the bladder. Bladder The 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? Urethra Urine 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 Urination Brain structures influence bladder function. Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxation Bladder 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 Problems The most common problems involve _____________________________________________ or ________________________________________. Problems can result from 1. I_________________________________________________________ 2. I_________________________________________________________ 3. O_________________________________________________________ 4. I_________________________________________________________ 5. I_________________________________________________________ Urinary retention_________________________________________________________ Urinary tract infection_________________________________________________________ CAUTIs Urinary 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 conduit Nephrostomy tubes Nursing 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 patients 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 assessment Kidneys___________________________________ Bladder___________________________________ External genitalia and urethral meatus___________________________________ perineal skin___________________________________ Assessment of urine Intake and output___________________________________ Characteristics of urine___________________________________ Color___________________________________ Clarity___________________________________ Odor___________________________________ External genitalia and urethral meatus Perineal skin Laboratory and Diagnostic Testing Diagnostic 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 incontinence Stress urinary incontinence Urge urinary incontinence Risk for infection Toileting self-care deficit Impaired skin integrity Impaired urinary elimination Urinary retention Planning Goals and outcomes Set realistic and individualized goals along with relevant outcomes Collaborate with the patient Setting priorities___________________________________________________________ Patients immediate physical and safety needs Patient expectations and readiness to perform some self-care activities Teamwork and collaboration______________________________________________________ Health promotion_____________________________________________________ Patient education_____________________________________________________ Promoting normal micturition_______________________________________________ Maintaining elimination habits Maintaining adequate fluid intake Promoting complete bladder emptying______________________________________________ Preventing infection____________________________________________________ Acute care Catheterization__________________________________________________________________ Types 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 catheters Urinary diversions Ø Incontinent diversions Changing a pouch Gently cleanse the skin surrounding the stoma Measure the stoma and cut the opening in the pouch Remove the adhesive backing and apply the pouch Press firmly into place over the stoma. Observe the appearance of the stoma and surrounding skin. Continent diversions Orthopic neobladder Medications Antimuscarinics: treat urgency, frequency, nocturia and urgency UI Bethanechol: treat urinary retention Tamsulosin and silodosin: relax smooth muscle Finasteride and dutasteride: shrink the prostate Antibiotics: treat urinary tract infections Be familiar with the medications and indications for all medications your patient is taking. Continuing and restorative care Lifestyle changes Pelvic floor muscle training Bladder retraining Toileting schedules Intermittent catheterization Skin care Evaluation Through the patients eyes Assess the patients self-image, social interactions, sexuality, and emotional status Patient outcomes Use the expected outcomes developed during planning to determine whether interventions were effective Evaluate for changes in the patients voiding pattern and/or presence of symptoms Evaluate patient/caregiver compliance with the plan Safety Guidelines for Nursing Skills Follow principles of surgical and medical asepsis as indicated Identify patients at risk for latex allergies Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine. Scientific Knowledge Base_______________________________________________________________ Mouth_____________________________________________________________________ Esophagus_____________________________________________________________________ Stomach_____________________________________________________________________ Small intestine__________________________________________________________________ Large intestine__________________________________________________________________ Anus_____________________________________________________________________ Defecation_____________________________________________________________________ Nursing Knowledge Base: Factors Affecting Bowel Elimination Age_____________________________________________________________________ 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 Diversions Temporary or permanent artificial opening in the abdominal wall. Stoma___________________ Surgical opening in the ileum or colon. Ileostomy or colostomy Ostomies Sigmoid colostomy Transverse colostomy Ileostomy Loop colostomy End colostomy Other Approaches Ileoanal pouch anastomosis Continent ileostomy Antegrade continence enema Critical Thinking Integrate the knowledge from nursing and other disciplines to understand the patients 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 measures Nursing Process: Assessment Through the patients 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 patients perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patients problems. Elimination factors (Box 47.3 Nursing assessment questions) Elimination pattern Stool characteristics Routines Bowel diversions Appetite changes Diet history Daily fluid intake Surgery or illness Medications Emotional state Exercise Pain or discomfort Social history Mobility and dexterity Physical assessment Mouth Abdomen Rectum Laboratory tests: Fecal specimens Diagnostic examinations: Direct visualization Indirect visualization Bowel preparation Nursing Diagnosis: Some diagnoses that apply to patients with elimination problems include: Disturbed body image Bowel incontinence Constipation Perceived consti
pation Risk for constipation Diarrhea Nausea Deficit knowledge (nutrition) Planning Goals and outcomes Incorporate elimination habits or routines Reinforce routines that promote health Consider preexisting concerns Setting priorities Patients often have multiple diagnoses Teamwork and collaboration Implementation: Health Promotion Routine Colorectal cancer Promotion of normal defecation Sitting position Privacy Positioning on bedpan Prevent muscle strain and discomfort Elevate head of the bed 30 to 45 degrees Wear gloves when handling bedpans Acute Care Environment Cathartics and laxatives Ø Cathartics have a stronger and more rapid effect on the intestines than laxatives Ø Suppositories may act more quickly than oral medications Antidiarrheal agents Opiates used with caution Enemas Cleansing enemas Tap water Normal saline Hypertonic solutions Soapsuds Oil retention Other types of enemas Carminative and Kayexalate Enema administration Sterile 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 stool Use if enemas fail to remove an impaction. Last resort in managing severe constipation Inserting and Maintaining a Nasogastric Tube Purposes Decompression, enteral feeding, compression, and lavage Categories 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 secretions Clean technique Maintaining patency Continuing and restorative care Care 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 ______________________________________________________ Evaluation Through the patients eyes_______________________________________________________ Patient outcomes ____________________________________________________________ 1. Medication Orders a. 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 orders i. Standing ii. Stat iii. PRN iv. Single 2. Routes of Administration define and discuss nursing considerations for each: a. Enteral i. Oral ii. Sublingual iii. Buccal iv. G-Tube/NGT v. Rectal b. Parenteral i. SQ · Angle of insertion: · Sites of administration: ii. IM · Angle of insertion: · Sites of Administration: iii. ID · Angle of insertion: · Sites of Administration: iv. IV v. What is the purpose of the Z-track method? When is it performed? c. Topical i. Eye Drops ii. Eardrops iii. Nasal drops iv. Inhalers v. Lotion/cream/ointment/powder vi. Transdermal vii. Vaginal Critical Thinking Scenario: The patient, Mr. Koop, has deteriorated over the shift. s 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 nurses next action? 3. Define each of the Rights of Administration: a. Medication b. Dose c. Patient d. Route e. Time f. Documentation g. Indication h. Response i. Refuse 4. Explain the Checks of Medication Administration a. First b. Second c. Third Critical 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 Considerations a. Infants/Children b. Elderly 8. Other Considerations for Med Administration a. 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 patients medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurses 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 patients call light and finds the patient sitting up in bed and requesting pain medication. What will the nurse do first? 1. Define: a. Pharmacology b. Pharmacotherapeutics c. Pharmacokinetics d. Pharmacodynamics 2. How are Drugs Classified? · What is the difference between them? · Why do nurses need to know about pharmacology? 3. Define: a. Absorption b. Distribution c. Metabolism d. Excretion 4. Factors affecting Absorption a. Dosage b. Dosage Form i. Enteric coated ii. Extended release c. Define the Routes i. Parenteral ii. Enteral iii. Topical d. GI function Identify 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 epidermis 5. Factors affecting Distribution a. Blood Flow b. Blood Brain Barrier 6. Factors affecting Metabolism a. First pass effect i. Which medication, oral Tylenol or IV Tylenol, has a higher bioavailability level? Why? b. Protein Binding 7. Drug Action on the Cell a. Stimulate cell function b. Inhibits cell function 8. 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 suctioning 9. A patient who has had gastric bypass surgery may have difficulty with which aspect of pharmacokinetics? 10. Define the Phases of Clinical Trials a. Phase I b. Phase II c. Phase III d. Phase IV Identify 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 Drugs 12. Names of Drugs a. Chemical b. Generic c. Trade/Brand 13. Provide the chemical, generic, and a trade name for the following: · azithromycin · diphenhydramine · meloxicam Critical 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 Standards a. FDA b. US Pharmacopeia c. National Formulary d. Hospital Formulary e. Physicians Desk Reference f. Prescription g. 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 Monitoring a. Therapeutic drug monitoring b. Half-life c. Onset · Why is a drugs half life listed in a drug reference book? · When is the use of drugs with short half lives indicated? d. Peak & Trough e. Minimum Effective Concentration f. Therapeutic Range g. Toxicity · : 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? ___________ · : 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? __________ · : 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. Pharmacodynamics a. Potency b. Efficacy c. Agonist d. Partial agonist e. Antagonist · : 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 Interactions i. Additive effect ii. Antagonistic effect iii. Synergistic effect iv. Incompatibility · Differentiate between additive, synergistic and antagonistic drug effects. g. Drug Diet Interactions 17. Identify the food the patient should avoid when taking the following medications and why should it be avoided: · · Atorvastatin · Warfarin 18. Variable affecting Drug action a. Age b. Gender c. Disease process d. Ethnicity e. Genetic f. Dosage · : 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? · : 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 Categories a. Define each category: i. A ii. B iii. C iv. D v. X b. Teratogenic effects 20. Drug Effects: Define each term: a. Therapeutic effect b. Side effect c. Adverse effect d. Drug toxicity e. Drug allergy f. Anaphylaxis g. Drug tolerance h. Drug dependence i. Cumulative effect j. Idiosyncratic effect k. Addiction 21. 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 of the larynx ____ Administration of Benadryl results in unexpected hyperactivity 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 itching 22. Pharmacotherapeutics a. Maintenance therapy b. Prophylactic therapy c. Therapeutic index · : 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? · As the triage nurse in a busy ER, you determine the patients 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?