Adult Health Exam 3

Why is delegation important in nursing?

• Your State Board of Nursing Licensure requires it

  • State Nurse Practice Act

• Nurses cannot do everything

  • Safe and competent patient care is complex

  • A team approach is needed

  • Interprofessional collaboration is essential to healthcare

• Both the American Nurses Association (ANA) and the National Council for State Boards of Nursing (NCSBN) support nurses in using delegation safely and effectively

Delegation vs. Assigning

• Delegation involves transferring authority to perform a task to another qualified individual

  • The person who delegates the task is still accountable

• Assigning involves transferring the authority and the accountability of a task to another qualified individual

• In each case, the individual chose must be appropriately trained to take on the task in question

5 Rights of Delegation

Delegation - Factors to Consider

• Your role at work

• Different facility policies

• Your own personal experiences

• Public misperceptions

Delegation - Members of the Team

• RN

  • Is a licensed nurse

  • Program of completion varies but is ~ 120 hrs

  • Must pass the NCLEX- RN

  • License governed by State Board of Nursing

• LPN

  • Is a licensed nurse

  • Program of completion varies but is ~ 60 hrs

  • Must pass the NCLEX- PN

  • License governed by State Board of Nursing

• UAP

  • Is unlicensed

  • Some programs offer  a certificate

  • Facilities can determine and offer required training

Delegation - Score of Practice: RN, LPN, UAP

• RN

  • Initial assessment (admin, post-op)

  • Assessment of unstable clients

  • Admin IV push, blood products, TPN, and meds requiring titration/continuous monitoring

  • Access implanted devices

  • Interpret and analyze data requiring complex critical thinking

  • Care plan development

  • Initial and discharge teaching

• LPN

  • Monitor RN findings and gather data (obtain BP, HR, etc)

  • Assessment of stable clients (focused and subsequent assessments)

  • Basic pt care (changing bandages, inserting catheters)

  • Report client status and concerns to RN/HCP

  • Care for stable clients with predictable outcomes (chronic, expected findings, ready for discharge, current labs)

  • Reinforce RN education

• UAP

  • Assist client with ambulation, ROM< hygiene, and activities of daily living (ADLs)

  • Feeding and oral care for stable clients (not if risk of aspiration)

  • Record routine vital signs and I&Os (may measure UOP from indwelling catheter bag)

  • Positioning and linen change

  • Transfer/transport (to/form bed, chair, commode, stretcher)

  • Report client status and concerns to RN

Delegation - Facility Specific Training

• Facilities can train LPN’s to perform tasks outside their scope of practice

• Facilities can train UAPs to perform tasks outside their scope of practice

• The RN retains accountability for supervision and safe execution of these tasks

RN CANNOT Delegate

• Any task that involves:

  • Clinical reasoning

  • Requires nursing judgement

  • Involves critical decision making

  • Involves the nursing process

  • Is above the scope of practice for the LPN or UAP

The nurse is planning care for a group of clients. Which task should the nurse assign to the licensed practical nurse (LPN)?

A. Assisting a client with crutch walking following knee replacement surgery.

B. Analyzing lab data to identify issues for a client who has diabetes mellitus.

C. Performing an admission assessment on a postoperative client.

D. Developing the plan of care for a client following an amputation.

A. Assisting a client with crutch walking following knee replacement surgery.

The nurse is caring for several clients. Which task is most appropriate to delegate to the unlicensed assistive personal (UAP)?

A. Assisting the client with preparation of a sitz bath

B. Walking the post-operative client that just returned from surgery

C. Coaching the client to deep breath during painful procedures

D. Monitoring the client for signs of discomfort while ambulating

A. Assisting the client with preparation of a sitz bath

The RN is caring for a group of clients. Which tasks can be delegated to the LPN? Select all that apply

A. Provide discharge instructions to a client's spouse

B. Obtain vital signs for a client who is 8 hours post-op

C. Administer oral pain medication to a client who is 1 day post-op

D. Initiate a care plan for a client who was admitted last night

E. Administer insulin to a client who is diabetic

B. Obtain vital signs for a client who is 8 hours post-op

C. Administer oral pain medication to a client who is 1 day post-op

E. Administer insulin to a client who is diabetic

A nurse is delegating assignments for a nursing team that includes an unlicensed assistive personnel (UAP). Which tasks should the nurse delegate to the UAP? (Select All That Apply)

A. Bathe a client who had an amputation 2 days ago

B. Assist a client to ambulate using a gait belt

C. Explain a low-sodium diet to a client who has hypertension

D. Review oral hygiene with a client who is receiving chemotherapy

E. Measure and document a client's intake and output

A. Bathe a client who had an amputation 2 days ago

B. Assist a client to ambulate using a gait belt

E. Measure and document a client's intake and output

Renal/Urology - System Overview

Structures include kidneys, ureters, bladder, and urethra

Renal/Urology: Anatomical Components - Nephrons

• Cells of the kidneys

  • Responsible for filtration (urine production)

    • Consider renal replacement therapy when greater than 85% is damaged

    • Will autoregulate based on body’s needs

Renal/Urology: Anatomical Components - Ureters

Moves urine to bladder

Renal/Urology: Anatomical Components - Bladder

Houses urine to be excreted and prevents urine reflux into kidneys

Renal/Urology: Anatomical Components - Urethra

Eliminates urine from bladder

Renal Physiology

• Control of blood pressure

• Control of water balance

• Excretion of waste via urine formation

• Regulation of electrolytes

• Regulation of acid-base balance

• Regulation of red blood cell production

*Production of ADH in the kidneys helps with fluid balance and BP management

Common Urinary Symptoms

*400 mL of urine per day is the estimated minimum of what is needed to rid the body of waste

Renal/Urology - Nursing Assessment

• Head-to-toe focusing on abdomen, suprapubic region, genitalia, low back and lower extremities

• Palpation of the kidneys is not usual, this may indicate enlargement

• Physical symptoms

  • Pain characteristics are important for diagnosing

    • Is it dull or achy? sharp or stabbing? where is it? are you having any other symptoms along with the pain?

  • Changes in voiding patterns or urine appearance

  • Are GI symptoms present? N/V, diarrhea, abdominal pain or discomfort

  • Unexplained anemia

• Health history

  • Ask about risk factors

  • Previous stones or UTI

• Family history

  • Genetically passed disorders

    • EXs: polycystic kidney disease (PKD), renal cystic diases, diabetes, CAD, pulmonary HTN

  • Male inferility or cystic fibrosis

  • Renal tumors or cancers

Risk Factors for Renal + Urologic Disorders

Diagnostics for Renal Function - Urine Tests: Urinalysis (US)

Checks color, clarity, pH , specific gravity, and presence of cells/protein/glucose/ketones

Diagnostics for Renal Function - Urine Tests: Urine Culture and Sensitivity (C&S)

Diagnostics for Renal Function - Urine Tests: 24-Hour Urine Collection

• 24-hour urine collection

  • Daily urine output (UO) - normal is 1 mL/kg/hr (1-2L/day)

  • Picture of the kidney’s ability to clear solutes from plasma

  • Usually measuring creatinine in urine

Diagnostics for Renal Function - Urine Tests: Osmolality

• Measures presence of solutes in urine

• Normal range: 200-800 (less is best!)

Diagnostics for Renal Function - Urine Tests: Specific Gravity

• Measures density compared to water

• Normal range is 1.005-1.025

• Abnormal low can be from diabetes insipidus, glomerulonephritis, and hyperhydration

• Abnoraml highs can be from diabetes mellitus, nephritis, and dehydration

Diagnostics for Renal Function - Blood Tests: BUN

8-20 mg/dL

• Blood urea nitrogen (end-product of protein metabolism)

• High levels indicate the kidneys are not filtering well

Diagnostics for Renal Function - Blood Tests: Creatinine

Male: 0.6-1.2 mg/dL; female: 0.4-1 mg/dL

• Waste product that is not filtered appropriately in presence of renal damage

Diagnostics for Renal Function - Blood Tests: eGFR (Glomerular Filtration Rate)

• Used to identify the stage of kidney disease

• Decreases naturally with aging changes

  Age (years)	Average eGFR
  20–29	116
  30–39	107
  40–49	99
  50–59	93
  60–69	85
  70+	75

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• Upper and lower urinary tract function changes with age

• The GFR decreases, starting between 35-40 years of age, and a yearly decline of about 1 mL/min continues thereafter with a notable decrease in GFR by as much as 30%-50% by age 70

• Older adults are more susceptible to AKI and CKD due to structural and functional changes in the kidney

• Kidney function results may be within normal limits until the GFR is reduced to less than 50% of normal

GFR Classifications

Stage	Description	eGFR	Kidney Function
1	Possible kidney damage (e.g., protein in the urine) with normal kidney function	90 or above	90-100%
2	Kidney damage with mild loss of kidney function	60-89	60-89%
3a	Mild to moderate loss of kidney function	45-59	45-59%
3b	Moderate to severe loss of kidney function	30-44	30-44%
4	Severe loss of kidney function	15-29	15-29%
5	Kidney failure	Less than 15	Less than 15

Gerontologic Considerations - Renal

• GFR begins to decrease 1 point/year starting at age 35-40

• Increased risk for AKI due to structural changes of the kidney

  • Sclerosis of renal tissues, decreased blood flow or perfusion, decreasing GFR, etc

• Increased risk for dehydration and hypernatremia with a decreased stimulation of thirst

Gerontologic Considerations - Urology

• Decreased bladder muscle tone and decreased vasopressin and ADH levels

  • Can cause an increase of residual urine

    • Often have incomplete emptying of the bladder and/or urinary stasis which increase the risk of a UTI and urinary urgency

    • Increased likelihood of nocturia

  • Increased likelihood of urinary incontinence

    • Also maybe related to mobility

• May self-limit fluid intake - watch for dehydration

• Symptoms may appear as other GI issues making diagnosis difficult

Acute Kidney Injury

• Renal damage resulting in a rapid loss of function (impaired filtration/regulatory functions)

• Criteria (only one must be present)

  • Increase in baseline serum Cr by 50% or more

  • An increase of 0.3 mg/dL within 48 hours

  • Decreased UO <0.5 mL/kg/h x 6 hours

• Can progress to ESKD (end stage kidney disease) if not treated quickly

• Changes to BUN, Cr, and GFR

• Metabolic complications such as acidosis and/or fluid and electrolyte imbalances

• Urine output (UO) may or may not be affected

• Patients may appear critically ill showing signs of lethargy, drowsiness, headache, muscle twitching, seizures

• Mortality rate can be as high as 80% - prevention is essential

• Critical illness symptoms mostly reflect the symptoms of electrolyte imbalance

Phases of AKI - Initiation (1)

Begins at the initial insult to kidney function and ends when the oliguria phase starts

Phases of AKI - Oliguria (2)

Increase of serum concentration of substances usually excreted by kidneys (ex - creatinine, K+, phosphorous, magnesium); UO drops to 400 mL/day or less

• Watch for uremic symptoms, life threatening electrolyte imbalances such as hyperkalemia may also develop

• Some patients may be non-oliguric and still maintain normal UO of 1-2 L/day, but the substances which should be excreted are not being filtered out

*Do not confuse the “oliguria” phase with the definition of oliguria as a urinary symptom

Phases of AKI - Diuresis (3)

Gradual increase in GFR and UO, stabilization of labs with possible decrease

• Continue to monitor for uremic symptoms and for possible dehydration

Phases of AKI - Recovery (4)

Labs return close to patient baseline; permanently decreased GFR will be present (1-3%)

AKI - Causes

• Changes to perfusion

  • Intravascular volume depletion

  • Impaired cardiac function/decreased CO

  • Vasodilation

  • Increased diuresis (physiological or med)

• Injury to renal tissue (renal ischemia)

  • Infections or obstruction in the renal/urologic tract

  • Transfusion reactions or hemolytic anemia

  • Trauma/crushing injuries

  • Rhabdomyolysis

    • Clinical syndrome characterized by injury to skeletal muscle fibers with disruption and release of their contents into the circulation

    • Myoglobin, creatine phosphokinase (CK) and lactate dehydrogenase are the most important substances for indicating muscle damage

    • Rhabdomyolysis-induced acute kidney injury (RIAKI) occurs following damage to the muscular sarcolemma sheath, resulting in the leakage of myoglobin and other metabolites that cause kidney damage

  • Nephrotic agents (NSAIDS, ACE inhibitors, chemicals, contrasts, etc)

AKI - Treatments

Goal: To restore normal chemical balance and prevent further complications

• Identify and eliminate/treat the underlying cause if possible

• Provide renal replacement therapy when ordered (KRT/RRT)

  • HD; PD; CRRT

• Assess/monitor fluid balance:

  • Daily weights, CVP< I/O balance, total UO per 24 hours

• Nutrition support: high calorie and high protein, restrict Na, K, phosphorous

• Assess physical condition and labs

  • Turn, cough, deep breathe to prevent atelectasis and pneumonia

  • Skin care - bather with cool water and reposition frequently

    • The skin may be dry or susceptible to breakdown due to edema; therefore, meticulous skin care is important

    • Excoriation and itching of the skin may result from the deposit or irritating toxins in the patient’s tissues

• Strict asepsis

  • Infection prevent with all catheters and vascular access devices

  • Treat fevers quickly

• Plan + provide individualized education and psychosocial support

Types of Urology Disorders

• Urinary tract infections

• Adult voiding dysfunction

• Urolithiasis and nephrolithiasis

• Urinary cancers

Urinary Tract Infections

• Occurs when a pathogen enters the urinary tract, remember this system is sterile above the urethra

• Identified by location: upper or lower

  • Upper UTIs include pyelonephritis, interstitial nephritis, and abscess (renal or perirenal)

  • Lower UTIs include cystitis (bladder), prostatitis (prostate), and urethritis (urethra)

• If not treated, can lead to AKI, CKD, or urosepsis

• Accounts for over 8 million healthcare visits/year

  • More common in females

• CAUTI is the most common healthcare-associated infections and cause of secondary bloodstream infections

  • CAUTI is a UTI associated with indwelling urinary catheters

  • A UTI that occurs while the pt has an indwelling urinary catheter in place for more than 2 calendar days on the day that the infection was detected

Urinary Tract Infections - Risk Factors

• General risk factors

  • Bacteria in the urinary tract

  • Female gender - anatomy (shorter), pregnancy, and intercourse

  • Comorbidities such as DM or gout

  • Immunosuppression

  • Urinary stasis and/or backwards flow

  • Instrumentation of the urinary tract (catheters/procedures)

  • “HARD TO VOID” acronym (another flashcard)

• Age-related (geriatric) risk factors

  • Cognitive impairment

  • Frequent use of antimicrobials

  • Multiple chronic medical conditions

  • Immunocompromise

  • Immobility

  • Incomplete emptying of bladder

  • Low fluid intake, dehydration

  • Poor hygiene/stool incontinence

“Hard to Void”

• Hormone changes (pregnancy, menopause)

• Antibiotics (changes the normal flora)

• Renal stones (obstructs flow of urine)

• Diabetes (high glucose levels and poor immunity)

• Toiletries (powders, perfumes, bubble baths)

• Obstruction - BPH (enlarged prostate), masses/tumors

• Vesicoureteral reflux *urine returns to the ureters - usually congenital)

• Overextended bladder (immobility, spinal cord injury, etc)

• Invasive (intercourse, indwelling catheters, procedures)

• Disease states (remember the disease related complications)

Urinary Tract Infections - Supporting Data

• Physical assessment:

  • Abnormal abdominal findings, back/suprapubic/pelvic pain

  • Urinary symptoms

    • May be asymptomatic (common with an indwelling catheter)

    • The nurse should inquire about association of symptoms with personal activity (ex - intercourse, hygiene, etc)

• Urine characteristics: appearance with UA w/ C&S

• Kidney/bladder ultrasound

Urinary Tract Infections - General Nursing Interventions

• Treat with providers’ orders

  • Pain relief - use heat therapy or med if ordered (analgesics and antispasmodics)

  • Antibiotics or anti-infectives

• Increase fluid intake, but avoid irritants like coffee, tea, citrus, alcohol, etc

• Pt education

  • Treatment compliance

  • Prevention of reoccurence by controlling modifiable risk factors

  • Cranberry juice/supplement for prevention of recurrent UTI

    • Reduce UTI incidence by 30%

Lower UTI

• Bacteria migrates to the bladder and causes an infection

  • Most commonly, fecal organisms (like E. coli) migrate via the transurethral route

• Reflux of urine from the urethra into the bladder (urethrovesical)

  • Commonly happens when coughing, sneezing, or straining due to an increase of bladder pressure that pushes urine into the urethra, as pressure decreases, the urine flows back to the bladder and can carry bacteria with it

Lower UTI - Nursing Considerations

• Additional assessment findings

  • Elderly - incontinence, delirium, decreased sensation leading to no report of symptoms

  • Post-menopausal women - malaise, nocturia, incontinence, foul-smelling urine

• Confirm with UA or basic labs, no diagnostics needed unless there is concern for spreading infection or complication

• Treatment typically involves a pharmacologic agent

  • Anti-infective/antibiotics and urinary analgesics; 3-5 days

• Nursing interventions:

  • Assess/monitor virals and I&Os

  • Use external catheters, not indwelling

  • Monitor for spesis and other complications like pyleonephritis or kidney fialure

  • Patient education related to treatment and prevention

Upper UTI

• Typically caused by bacteria traveling upward from the bladder or from a blood stream infection that reaches the kidneys

  • AKA: pyelonephritis - bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

  • Other causes can be interstitial inflammation, abscess, kidney damage, tubular cell necrosis, a bladder infection, urinary stasis, or obstructions (tumors/structures/BPH) that cause reflux from the bladder into either or the ureters (ureterovesical or vesicoureteral reflux)

• Less common that lower tract infections, but a more common cayse or urosepsis

Upper UTI/Pyelonephritis - Nursing Considerations

• Additional assessment findings

  • Acute - physical assessment may show chills, fever, low back/flank pain, N/V, headache, malaise

    • The chronic condition happens after several acute episodes that leave scar tissue on the kidneys, resulting in permanent kidney damage

  • Chronic - asymptomatic unless the patient is experiencing an acute exacerbation and may also show fatigue, poor appetite, polyuria, excessive thirst, and weight loss

• CT imaging, ultrasound, or a pyelogram may also be ordered with UA and labs

• Treatment typically involves a pharmacologic agent

  • Anti-infective/antibiotics and urinary analgesics; 2 weeks

• Nursing interventions:

  • Assess/monitor vitals and I&Os

  • Monitor for complications: ESKD, HTN, and renal calculi

  • Patient education to prevent further infection

Patient Education for Upper and Lower UTIs

• Promote adherence to antibiotic regimen

  • Don’t stop because symptoms stop

• Promote increased water intake - 3-4L per day

  • Monitor their own I&Os and notify MD of abnormal changes to urine appearance/volume

  • Encourage/promote frequent voiding (go when you feel the need, and every 2-3 hours)

• Maintain good perineal hygiene, especially important for dependent/incontinent patients

• Urinate before and after intercourse

• Preventive measures for any modifiable tasks

Types of Voiding Dysfunction

• Incontinence - “involuntary loss of urine”

  • Stress - happens with sneezes, laughing, exertion, etc… (no structural changes)

    • M - after prostatectomy, F - after pregnancy

  • Overflow - overdistended bladder due to bladder muscle dysfunction or obstructed outflow

  • Urge - aware of need to void but can’t get to a toilet quickly enough

  • Functional - physical or cognitive impairment

  • Latrogenic - external medical factors (ex - meds)

  • Mixed - combo of factors

• Retention - “incomplete emptying”

Voiding Dysfunction - Incontinence

• Assessment should include discussion of symptoms