Urinary Elimination
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 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 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___________________________________________________________
Patient’s immediate physical and safety needs
Patient expectations and readiness to perform some self-care activities
Teamwork and collaboration______________________________________________________
Implementation
Health promotion_____________________________________________________
Patient education_____________________________________________________
Promoting normal micturition_______________________________________________
• Maintaining elimination habits
• Maintaining adequate fluid intake
Promoting complete bladder emptying______________________________________________
Preventing infection____________________________________________________
Acute care
Catheterization__________________________________________________________________
Skill 46-2, Inserting and Removing a Straight (Intermittent) or Indwelling Catheter
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 patient’s eyes
Assess the patient’s 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 patient’s 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.
Bowel Elimination
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 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 measures
Nursing Process: Assessment
Through 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 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 constipation
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. 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. 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 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 I
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. Physician’s 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 drug’s 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
· 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. Pharmacodynamics
a. Potency
b. Efficacy
c. Agonist
d. Partial agonist
e. 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 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:
· Ciprofloxacin
· Atorvastatin
· Warfarin
18. Variable affecting Drug action
a. Age
b. Gender
c. Disease process
d. Ethnicity
e. Genetic
f. 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 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
· 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?
