Foundations exam 3

Nephron

Functional unit of the kidney, forms urine

Contains glomerulus, Bowman’s capsule, PCT, DCT, CD, loop of henle

125ml/min filtered through glomerulus and 99% is reabsorbed, 1% is excreted as urine

Normal: 1500-1600ml/ 24hrs

GFR

Glomerular filtration rate

Normal: 90 or higher is generally considered normal

Below 60 for more than 3 months= CKD

Below 15= kidney failure

Urination

The innervation of the bladder signals when it is time to urinate and empty the bladder (urge or urgency)

The brain signals the bladder muscles to tighten and the sphincter muscles to relax, which squeezes urine out of the bladder through the urethra

When all signals occur in the correct order, normal micturition, or urination, occurs

Normal urine characteristics

Urine can be dilute or very concentrated, normal urine is sterile, it contains fluids, salts, waste products, but it is free of bacteria, viruses, and fungi

Urine can be produced by the innervation of the bladder, signaling when it is time to urinate and empty the bladder (urge)

The brain signals the bladder muscles to tighten and the sphincter muscles to relax, which squeezes urine out of the bladder through the urethra

When all the signals occur in the correct order, normal micturition (urination), occurs in small or large

Kidneys

An output of less than 30ml per hour may indicate renal problems (CKD, KF, dialysis)

Factors influencing urination

Growth and development: infants and children cannot effectively concentrate urine

• Aging impairs micturition, glomerular filtration rate decreases, the ability to concentrate urine declines, and the bladder loses tone (UTI, weakness, dementia)

Psychological factors: anxiety and stress may cause a sense of urgency and frequency, emotional tension may make it hard for the person to relax, resulting in urinary retention

Muscle tone: pregnancy, menopause, damage from trauma

Food and fluid intake, surgical procedures, medications

Medications impact on urination

Diuretics (Furosemide): increases urine output

Anticholinergics (Atropine Sulfate): decreases urine output

Antihistamines (Sudafed): decreases urine output

Hypnotics and sedatives: may decrease the ability to recognize and act on the urge to void

Urinary retention

The inability of the bladder to empty, caused by an obstruction in the urinary tract or by a neurologic disorder

Characteristics: difficulty starting a stream or emptying the bladder, weak urine flow, chronic or acute pain, discomfort, pain, anxiety, pressure, tenderness

UTI

Urinary tract infections are the result of bacteria in the urine, single most common hospital acquired infection

Females are more vulnerable than males, with the rate of occurrence gradually increasing with age

People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and the elderly with bladder control loss

Confusion, loss of appetite, incontinence, falls

Prevention of UTI

Prevention is key

Treatment requires antibiotics, 80% are the result of catheterization

Urinary incontinence

The complaint of any involuntary loss of urine

Transient incontinence: medical conditions, treatable and curable

Functional incontinence: Cognitive impairment, deficits, poor malnutrition, failure to thrive

Stress incontinence: laughing so hard you pee

Urge or urgency incontinence: Overactive bladder, can’t hold once urgency occurs

Reflex urinary incontinence: somewhat predictable, when reaches specific bladder level

Anuria

Failure to produce or excrete 50 to 100ml of urine in 24hrs

Failure of kidneys to excrete urine, results from any process that limits effective blood flow through the kidneys

Inadequate flow or complete obstruction by anything that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure

Acute anuria is life threatening and requires emergent investigation to determine the cause

Oliguria

Reduced volume, 100-400ml in 24hrs

A symptom of acute or chronic renal failure

Revealed by monitoring urinary output

Classified: prerenal from reduces blood flow to the kidneys, renal from actual renal damage, postrenal failure from obstruction of urine flow

Polyuria

Excessive production and excretion of urine

2500ml or more of urine a day

Nocturia

Excessive urination at night

Disrupts sleep cycle, associated with the use of medications such as diuretics, as well as urinary teact infections, congestive heart failure, cystitis, and diabetes

Dysuria

Painful urination

Many causes are possible, burning, delay in initiating voiding may be associated

Hematuria

Blood in the urine

Gross, visible, or microscopic blood may represent a serious underlying disease

Urine color does not reflect the degree of blood loss

Urinary incontinence

The inability to control urination

Urinary retention

Inability to empty the bladder fully

Hemodialysis

The patient’s blood flows continually from the body through vascular catheters to the dialysis machine

Peritoneal dialysis

Performed by instilling dialysis solution into the patient’s abdominal cavity through an external catheter

Urinary diversion

Surgical procedure performed when bladder function is impaired due to trauma or disease involving the bladder, and or the distal urethra

Suprapubic catheter

Inserted directly into the bladder just above the pubic bone

Surgical placement of a suprapubic catheter may be undertaken if urethral cathetrization is either contraindicated or unsuccessful

Assessment of urine

Intake and output

Color, clarity, odor

Urinary testing: random specimen, clean voided or midstream specimen, sterile specimen, timed urine specimen

24 hour urine

Taken to determine the amount of creatine cleared through the kidneys

Also used to measure levels of protein, hormones, minerals, and other chemical compounds in urine

Discard first urine

Common urine tests

Urinalysis: pH (4.6-8)

• none of: protein, glucose, ketones, blood, WBCs, bacteria, casts

Specific gravity (1.010- 1.025)

Urine culture

GI tract

Mouth, esophagus, stomach, small intestine, large intestine, anus

Gut microbiome: trillions of microbes

Factors influencing bowel elimination

Age, diet, fluid intake, physical activity, psychological factors, pain, pregnancy, surgery and anesthesia, medications

Common bowel elimination problems

Constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids

Paralytic ileus

Temporary obstruction of the intestines by the failure of muscle contractions

Hypoactive bowel signs

Decreased gas, get them moving, repositioning

Characteristics of stool

Type 1: rabbit droppings

Type 2: bunch of grapes

Type 3: corn on the cob

Type 4: sausage

Type 5: chicken nuggets

Type 6: porridge

Type 7: gravy

Color of stool

Any shade of brown: good

A little green: alright

Super green: ate greens or its passing too fast

Black: iron supplements, bleeding in upper intestinal tract

Pale, white, clay colored: your bile duct may be blocked

Red: Hemorrhoids or bleeding in lower intestine

Yellow: too much fat, malabsorption, celiac disease on your diet

Straining stool

Increases pressure to expel feces by contracting the abdominal muscles, which maintains a closed airway (holding breath)

Cautions: patients with heart disease, glaucoma, increased intracranial pressure, new surgical wound

Bowel diversions

Ostomies (colostomy and ileostomy)

Thick liquid to soft paste

Chronic or temporary

Beefy red: good blood flow, pink: decreased blood flow, black: necrotic

Ileoanal pouch anastomosis

Restorative procedure creating a reservoir from the small intestine attached to the anus, allowing for normal defecation and eliminating the need for a permanent external ileostomy bag

Laboratory tests

Fecal occult blood: looking for blood in stool

Ova and parasites: worms and eggs

Stool culture: bacteria

Diagnostic procedures for GI

Colonoscopy

Endoscopic exams: esophagogastroduodenoscopy, sigmoidoscopy

X-ray with contrast medium: barium swallow, barium enema, MRI/CT scans

Medications for GI

Cathartics and laxatives: cathartics and laxatives empty the bowel for patients experiencing constipation

Antidiarrheal agents: provide symptomatic relief by acting on or within the bowel

Types of laxatives

Bulk forming: increase the bulk and softness of the stool, mimicking natural bowel function (metamucil)

Osmotic laxatives: pull water from surrounding tissues into the bowel to soften stool, effective for chronic constipation; Polyethylene glycol (Miralax), lactulose, milk of magnesia

Stimulant laxatives: irritate the intestinal lining, causing contractions that move stool quickly. Best for short term relief; Bisacodyl (Dulcolax, Senna)

Stool softeners: allow more water and fats to penetrate the stool, making it easier to pass

Lubricant laxatives: coat the stool with a waterproof film, keeping it moist and slippery

Enemas

Cleansing enema: promotes the complete evacuation of feces from the colon (tap water, normal saline, soap suds)

Oil retention

Carminative enemas

Milk and molasses

What position is the patient in for an enema

Sims position

Promoting healthy bowels

Exercise daily, relaxation techniques, don’t drink lots of caffeine, don’t smoke, avoid constipation drugs, drink plenty of fluids

Signs of cancer on the bowel

Change in bowel elimination patterns, blood in the stool, rectal or abdominal pain, change in character of stool, sensation of incomplete emptying after a bowel movement

Decompression of GI tract

NG tube insertion, required for some conditions

Nursing care includes keeping the patient comfortable after tube insertion and keeping the tube patent

Nursing interventions for movements

Maintain mobility, prevent complications of immobility, promotion of venous return

Physiology of movement and alignment

Requires integrated function of skeletal system, muscular system, nervous system

Skeletal system

Joints: where two or more bones attach

Ligaments: white, shiny, flexible bands of fibrous tissue that bind joints together, connect bones and cartilages, and aid joint flexibility and support

Tendons: white, glistening, fibrous bands of tissue that connects muscle to bone and are strong, flexible, and inelastic

Cartilage: non-vascular supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear

Normal movement and alignment

Requires: body alignment or posture, balance, coordinated body movement, postural reflexes

Correct body alignment

reduces strain on musculoskeletal structures, aids in maintaining muscle tone, promotes comfort, contributes to balance and conservation of energy

Impaired balance: a major threat to mobility and physical safety, and it contributes to a fear of falling and self imposed activity restrictions

Body mechanics

Application of mechanical laws to the human body, proper body mechanics prevent injury, sore muscle and joints, a nurses day

Patient care ergonomics

Patient care handling tasks are the primary cause of M/S injuries in nurses

47% of US nurses have reported injuries to their back

Immobility

Affected by: illness, trauma, mental status, weight

Integumentary: increased pressure on skin, decreased circulation, potential for pressure ulcers

Respiratory: decreased respiratory movement, weakened respirator muscles, stasis of secretions

Metabolic: decreased BMR, decreased appetite, muscle wasting, weight loss

Elimination: urinary stasis, renal calculi, UTI

Neurologic/psychosocial: depression, changes in sleep pattern, behavioral changes, ineffective coping

Contractures

Immobility predisposes a person to weakness, decreased muscle tone, decreased bone and muscle mass, potential muscle atrophy, or contracture (permanent fixation) of a joint

Can begin within hours of disuse

Footdrop

A contracture that results in permanent plantar flexion

Benefits of exercise

Improves cardiovascular functioning, pulmonary functioning, coordination, muscle strength, weight control, intestinal tone, kidney function, sleep, energy

Types of exercise

Isotonic exercises: involves active movement with constant muscle contraction

Isometric exercise: requires tension and relaxation of muscles without joint movement

Aerobic exercise: requires oxygen metabolism to produce energy

Anaerobic exercise: builds power and body mass, without oxygen to produce energy for activity, anaerobic exercise takes place

Risks of exercise

Precipitation of a cardiac event, orthopedic injury, heat exhaustion or heat stroke, exacerbation of respiratory problems, overuse

Range of motion

Degrees of movement of a joint

Active ROM: full movement of each joint

Passive ROM: nurse passively moves each joint to the point of resistance while evaluating patient comfort level

Logrolling

To maintain the patient’s spinal alignment through special repositioning, maintain skin integrity, prevent pressure ulcers, promote patient comfort

Virchow’s triad

Three factors contribute to venous thrombus formation:

Damage to vessel wall, alteration of blood flow, hypercoagulability of the blood