ADULT HEALTH FINAL EXAM!

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: 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 - Kidney Replacement Therapy/RRT)

  • HD; PD -Peritoneal Dialysis; CRRT - Continuous Renal Replacement Therapy

• Assess/monitor fluid balance:

  • Daily weights, CVP - Central Venous Pressure, 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 - bathe 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 cause 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

  • A detailed description of the problem and a history of med use, the patients voiding history, a dairy of fluid intake and output, and any bedside test results (like a residual urine scan)

• Skin care!!

  • Skin breakdown can occur from incontinence-associated dermatitis (IAD), a type of moisture-associated skin damage caused by physical and chemical irritants

• Collaborate with the medical plan:

  • Non-pharmacologic interventions are the first choice of treatment: fluid management, voiding schedule/retraining, pelvic floor exercises

  • Pharmacologic can be used in conjunction with behavioral changes: first-line meds are anticholinergics (for inhibiting bladder contraction)

  • Surgery may be indicated when no meds or behavioral methods work

• Affects 9-12% of all adults

  • More common in women (nearly 2x the rate of men)

  • Up to 90% of elderly patients in institutions

• Often goes undiagnosed

  • Pts are embarrassed to seek help and may not want to discuss symptoms

Patient Education for Incontinence

• The nurse should educate the patient on: avoid bladder irritants (caffeine + alcohol) and artificial sweeteners such as aspartame

  • Increase awareness of the amount and timing of all fluid intake and avoid taking diuretics after 4 pm

  • Take steps to avoid constipation: drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take stool softeners if recommended

  • Void regularly 5-8x/day (about every 2-3 hours)

    • First thing in the morning; before each meal, before retiring to bed, once during the night if necessary

  • Perform all pelvic floor muscle exercises as prescribed every day

  • Stop smoking (if applicable)

  • Financial or community resources, discuss barriers to compliance

Voiding Dysfunction - Retention

Nursing Considerations:

• Changes with elderly: older adults may retain 50-100 mL due to changes in bladder tonicity

• Assessment/diagnosis can be challenging since symptoms can be vague

  • Ask the patient lots of questions to understand their voiding patterns:

    • What was the time of the last voiding, and how much urine was voided?

    • Is the patient voiding small amounts of urine frequently?

    • Is the patient dribbling urine?

    • Does the patient report pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly)

    • Is the pelvic area rounded and swollen (could indicate urine retention and a distended bladder)?

    • Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)?

    • Are other indicators of urinary retention present, such as restlessness and agitation?

  • Palpate for bladder distention and lower abdominal pain

  • Postvoid bladder ultrasound

• When untreated, this can lead to a UTI, calculi formation, pyelonephritis, and sepsis

• Nursing interventions:

  • Promote good body position for elimination

  • Apply warmth to perineum

  • Reduce caffeine

  • Request MD order for bladder ultrasound if needed

  • Straight cath if indicated, try to avoid indwelling catheters

Neurogenic Bladder

• A nervous system disorder that impacts voiding, by causing either incontinence or retention

  • Incontinence (functional): spastic muscle tone, empties with no controlling influence/regulation

  • Retention:

    • Flaccid muscle tone - no bladder contraction so the bladder becomes overdistended; must be straight cath’d to empty

    • May eventually lead to overflow incontinence when it is too full

• Complications include infection, impaired skin integrity, and renal calcili

• Treated with meds or with a voiding schedule; may need to straight cath on a schedule if the patient has retention

Urinary Catheters

• Types: indwelling/straight, indwelling, suprapubic

• Only use when absolutely necessary:

  • Retention/neurogenic bladder

  • Post-op following urological procedures

  • Stage 3-4 skin injuries of the perineum

  • Urinary tract obstruction

  • End-of-life care/critical illness care

• Nursing considerations:

  • CAUTI prevention

  • Catheter care “bundle”

    • Below the bladder, not of the floor, perineal care 2x/day and prn, secured to leg, no kinks in tubing

  • Identify true patient need

  • Advocate for external device and removal asap

  • Skin care (stat-lock and moisture)

  • Asepsis of catheter bag/ports, do not disconnect tubing for samples

Urolithiasis + Nephrolithiasis

• Causative substances

  • Increased serum calcium levels (most common type)

    • Calcium rich foods like dairy

    • Calcium oxalate foods - peanuts, dark leafy greens, beets, chocolate, sweet potatoes

  • Struvite

    • Starts from bacteria exposure

    • Most common type in women

  • Excess uric acid (acidic urine, pH < 5.5)

    • Common for people with large amounts of dietary protein (and gout)

    • Only about 10% of stones are this type

• Generally more common in men than women

• X-ray or non-contrast CT may be needed in addition to standard blood and urine tests

Renal Calculi - Nursing Considerations

• Assessment

  • Pain

  • Signs of obstruction - dysuria, hematuria, frequency/oliguria

  • Fever and chills

  • N/V

  • Diaphoresis + pallor

  • Elevated HR, RR, and BP

• Nursing Interventions

  • Provide analgesic therapy: opioids, NSAIDS, heat therapy to low back/flank area

  • Increase fluid intake, unless contraindicated; avoid activities that may cause sweating

  • Monitor for S/S of UTI and for blood/stones in urine (save stones for lab analysis)

    • Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region

    • Stones lodges in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain that radiates down the thigh and to the genitalia

  • Monitor I&O for oliguria/anuria

  • Draw + monitor ordered labs

    • Blood chemistries and a 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume may be part of the diagnostic workup

  • Dietary restrictions: foods high in protein, sodium, or oxalate

    • Sodium competes with calcium for reabsorption in the kidneys

    • Maintain daily recommendation of calcium, don’t restrict since it can lead to osteoporosis

• Medical procedures may be ureteroscopy, lithotripsy, or nephrolithotomy

Urinary Tract Cancers

• Cancers can be in any urinary organ: kidney, bladder, ureters, prostate, and surrounding structures

• Diagnostics include urinary imaging, CT, MRI, ultrasound, manual exam, and biopsy

Bladder Cancer

• Account for 16,000+ deaths/year

• 90% of cases are in age 55+

  • More common in men than women

  • Smoking is a leading risk factor

• Surgical treatment is radical cystectomy with urinary diversion

  • Transurethral resection or cauterization may be done for benign tumors

Prostate Cancers

• Over 70% of cases are in men 65+

• The second most common cancer in men (skin CA is #1)

• 2nd highest cancer-related death rate in men (lung CA is #1)

• If detcted early there is a high cure rate

  • Common lab - PSA; no true normal, the ideal is < 4 ng/mL

• Common surgery for treatment - TURP (transurethral resection of prostate)

Urinary Tract Cancers - Assessment

• Bladder CA: focus on urine characteristics mostly; UTIs, painless hematuria, and changes to voiding patterns are commonly seen

  • Back and pelvic pain typically is associated with metastasis

• Prostate CA: may include signs of obstruction, blood in urine or semen, and painful ejaculation

  • Sexual dysfunction is a common early sign

Urinary Tract Cancers - Nursing Interventions

• Admin of chemo/radiation

• Post-surgical care for incisions, drains, and/or stomas

• Maintain continuous bladder irrigation if order (hospitalized pt)

• Skin care

• Monitor urine

• Encourage fluid intake

• Pt education and emotional support

Nursing Diagnoses for Renal/Urological Disorders

• Acute pain

• Deficient knowledge

• Infection, risk for

• Eliminations, impaired urinary

• Retention, urinary (acute or chronic)

• Incontinence (be specific to which one)

• Electrolyte imbalance, risk for

• Fluid volume, risk for imbalanced

• Injury, risk for urinary tract

*Just a sample, there are more

GI Anatomy - Overview

Break down food → absorb nutrients → eliminate waste

GI Anatomy - Mouth

• Mechanical digestion (chewing)

• Saliva

• Amylase: starch → sugars

• Lipase: fats

GI Anatomy - Esophagus

Stores and mixes food → chyme

• Secretions

  • HCl: protein breakdown, bacteria destruction

  • Pepsin: protein digestion

  • Intrinsic factor: vitamin B12 absorption

  • Hormones

  • Gastrin: increases acid + motility

  • CCK: stimulates gallbladder + pancreas, decreases appetite

  • Secretin: increases bicarbonate release

GI Anatomy - Small Intestine

Doudenum → jejunum → ileum

• Primary site of digestion and absorption

• Enzymes

• Pancrease: trypsin, amylase, lipase

• Liver/gallbladder: bile → fat emulsification

• Motility

• Peristalsis: propulsion

• Segmentation: mixing for absorption

GI Anatomy - Large Intestine (Colon)

Ascending → transverse → descending

• Absorbs water and electrolytes

• Gut bacteria

• Break down leftovers

• Produce vitamins

• Protect against pathogens

• Secretions

• Bicarbonate: neutralizes acids

• Mucous: protects lining, stool movement

GI Anatomy - Rectum + Anus

• Rectum: stores stool

• External anal sphincter: voluntary control of defecation

Functions of the Digestive System

• Breakdown of food for digestion

  • Ingestion - taking food into the mouth

  • Mechanical digestion - chewing and stomach-churning break food into smaller pieces

• Absorption into the bloodstream of small nutrient molecules produced by digestion

  • Absorption - nutrients move from the small intestine into the bloodstream

  • Water reabsorption - the large intestine absorbs water and electrolytes

• Elimination of undigested unabsorbed foodstuffs and other waste products

  • Elimination - waste is expelled through the rectum and anus

  • Gut microbiome support - beneficial bacteria aid vitamin production, immunity, and waste breakdown

GI - Gerontologic Considerations

Normal physiologic changes of the GI system that occur with aging. Careful assessment and monitoring of S/S related to these changes are necessary. Older adult pts frequently report dysphagia, anorexia, dyspepsia, and disorders of colonic function.

Assessment of the GI System

• Healthy history

  • A focus GI assessment is info about abdominal pain, dyspepsia, gas, N/V/D, constipation, fecal incontinence, jaundice, and previous GI disease

  • Physical assessment

  • Past health, family, social history

• Pain

  • Presenting symptoms, character, duration, pattern, frequency, location, distribution or referred abdominal pain, and time of the pain vary greatly depending on the underlying cause

Assessment of the GI System - Health History

• Ask about:

  • Dental hygiene, dentures, mouth sores

  • Usual food and fluid intake

  • Current and past medications

  • Previous GI tests or procedures

  • Alcohol and tobacco use

  • Appetite or weight changes in the past year

Assessment of the GI System - Physical Assessment

• Inspection and palpation of:

  • Oral cavity, Lips: moisture, color, texture, symmetry, ulcers, fissures

  • Gums: inflammation, bleeding, recession, discoloration

  • Tongue: color, texture, lesions

• Abdominal Assessment

  • Use the four‑quadrant method:

  • Inspection

  • Look for skin changes, scars, lesions, discoloration, bruising, or visible masses.

• Auscultation

  • Assess bowel sounds—normal, hyperactive, hypoactive, or absent—and note their location and frequency.

• GI Pain Assessment

  • Evaluate: Pain

  • Character: sharp, dull, cramping

  • Duration: how long it lasts

  • Pattern/Frequency: when it occurs, what triggers it

  • Location: where the pain is felt

  • Radiation: whether it spreads to the back, shoulder, or other areas

Pain Assessment (GI Focus) - Abdominal Assessment (4-Quadrant Method)

• 1. Inspection

  • Look for skin changes, scars, lesions, discoloration, bruising, striae, or visible masses.

• 2. Auscultation

  • Listen for bowel sounds—normal, hyperactive, hypoactive, or absent—and note their location and frequency.

• 3. Percussion

  • Helps identify organ size and detect air, fluid, or solid masses.

  • Tympany: air‑filled areas (stomach, small intestine)

  • Dullness: organs or solid masses

• 4. Palpation

  • Light palpation: tenderness, guarding, muscle tension

  • Deep palpation: masses or deeper abnormalities

• Rectal Assessment

  • May be uncomfortable; use appropriate positioning (knee‑chest, left lateral, or standing with hips flexed).

  • Inspect for lumps, rashes, tears, scars, hemorrhoids, fistulas, fissures, or prolapse.

  • Ask the patient to bear down to reveal hidden abnormalities such as internal hemorrhoids or polyps.

GI - Common Sites of Referred Abdominal Pain

GI - Lab Studies

• CBC: Anemia or infection

• CMP: Electrolytes, kidney function, liver enzymes

• AST, ALT, bilirubin: Liver injury or disease

• PT/PTT: Clotting ability

• Amylase + Lipase: Pancreatic inflammation

• Triglycerides: High levels can stress the pancreas

• Cancer-specific labs

• Stool tests

• Breath test

• Genetic testing: Identifies risk for - gastric cancer, lactose intolerance, inflammatory bowel disease, colon cancer

GI: Lab Studies - Cancer-Specific Labs

• Cancer antigen (CA): Various GI cancers

• Carcinoembryonic antigen (CEA): Colorectal cancer

• Aplha-fetoprotein (AFP): Liver cancer (hepatocellular carcinoma)

GI: Lab Studies - Stool Tests

• Identify infection, inflammation, or malabsorption

  • Fecal urobilinogen: High or low levels suggest liver or bile duct issues

  • Fecal leukocytes: WBCs in stool → inflammation or infection

  • Parasites: Detects worms, eggs, protozoa (Giardia, Entamoeba, helminths)

  • Fecal fat: High levels indicate malabsorption (celiac, pancreatic insufficiency)

  • C. difficile: Detects bacteria causing severe diarrhea/colitis, often after antibiotics

  • Fecal Occult Blood Test (Guaiac): Detects hidden blood in stool, used for early cancer screening

• Avoid red meat, aspirin, NSAIDS for 72 hours (prevents false positives)

• Not used if hemorrhoids are actively bleeding

GI: Lab Studies - Breath Tests

• Hydrogen breath test: Carbs absorption and bacterial overgrowth

• Urea breath test: Detects H. pylori (peptic ulcer disease)

Diagnostic Imaging

Abdominal imaging tests help identify structural problems, inflammation, infections, or cancer

Diagnostic Imaging - Abdominal Ultrasonography

• Uses high-frequency sound waves to visualize organs

• Finds: enlarged gallbladder/pancreas, gallstones, enlarged ovary, ectopic pregnancy, appendicitis

• Nursing: fast 8-12 hours to reduce bowel gas; if gallbladder is a concern (fat-free meal before fasting)

• Do ultrasound before any barium studies (since it interferes with imaging)

Diagnostic Imaging - X-Ray

Shows the abdominal cavity and detects: masses, bowel obstruction, foreign objects, solid structures appear whiter on the image

Diagnostic Imaging - CT Scan (w/ or w/o Contrast)

• Provides detailed cross-section images of abdominal organs and structures

• Finds: appendicitis, diverticulitis, crohn’s/ulcerative colitis, liver/spleen/kidney/pancreas issues, pelvic organ problems, abdominal wall disease

• Nursing: screen for contrast risks (kidney issues, allergies, pregnancy)

  • Some pts need premed for contrast allergy

• Encourage hydration afterward to flush contrast

Diagnostic Imaging - MRI Scan (w/ or w/o Contrast)

• Detailed imaging of soft tissues and blood vessels

• Finds: abscesses, fistulas, tumors, bleeding sources

• Nursing: NPO 6-8 hours if possible

  • Remove all metal/jewelry

  • Screen for claustrophobia

  • Test lasts 60-90 mins

• Check for contrast contraindications

• Sedation may not be required, pt will lie flat for 15-25 mins

Diagnostic Imaging - PET Scan (Nuclear Imaging)

• Uses IV radioactive isotopes to detect abnormal metabolic activity, cells using more energy often for cancer evaluation

• Nursing: requires a working IV

  • Isotopes clear through urine and stool

  • Radiation exposure is low because isotopes decay quickly

Diagnostic Imaging - Barium Swallow (Upper GI Series)

• Barium sulfate (a radioplaque liquid contrast) is swallowed to detect disorders of esophagus, stomach, duodenum, and small intestine

  • Pt drinks liquid barium, coats upper GI tract

• Multiple x-rays are obtained to create a continuous x-ray image

  • Shows shape, movement, and structural abnormalities

  • Detects swallowing problems, esophageal strictures or tumors, hiatal hernia, ulcers, GERD-related changes

• Possible diagnoses: ulcers, varices, tumors, enteritis, and malabsorption syndromes

• Nursing points:

  • Low‑residue diet before the test

  • Clear liquids + PEG laxative the evening before (if ordered)

  • NPO after midnight; no smoking or gum chewing because they increase secretions

  • Hold morning medications unless the provider gives different instructions

  • Insulin may need adjustment when the patient is NPO (provider decides)

  • Post‑procedure: Encourage hydration to help pass the barium

  • Expect white or light‑colored stool for 1–3 days

Diagnostic Imaging - Barium Enema (Lower GI Series)

• Rectal instillation of barium that allows for visualization of the lower GI tract via x-ray

  • Barium is inserted into the rectum through a small tube; x-ray shows colon structure + movement

• Possible diagnoses: polyps, tumors, and lesions

  • Diverticula, inflammatory changes, structural issues (twisting, narrowing)

• Contraindications: active inflammatory disease, fistulas, perforation or obstruction of colon; active GI bleeding may prohibit use of laxatives and enemas

• Nursing points:

  • Low‑residue diet 1-2 before the test

  • Clear liquids + laxative the evening before

  • Morning enema may be needed until returns are clear

  • NPO after midnight

  • Post‑procedure: Encourage hydration and a high‑fiber diet to prevent constipation

  • Stool may appear white or light for 1–3 days

  • Patient may feel cramping or fullness during the test

  • Monitor bowel movements afterward

Endoscopic Procedures - Esophagogastroduodenoscopy (EGD)

• Direct visualization of esopahgeal, gastric (motility), and dudoneal mucosa

  • Collect secretions and tissue specimens

• Topical anesthetics and moderate sedation

• Diagnostic and/or therapeutic

• Pt may get atropine to reduce secretions and/or glucagon to relax smooth muscle

• Pt usually wares mouth gaurd to prevent biting the endoscope

• Nursing care:

  • NPO 8 hours before procedures

  • Priority during procedures: airway + oxygenation

  • Assess for signs of perforation

  • Relieve minor throat discomfort

  • Post-procedure education

• Therapeutic endoscopy

  • Remove common bile duct stones

  • Dilate strictures

  • Treat gastric bleeding and esophageal varices

Endoscopic Procedures - Colonoscopy

• Direct visualization of the large intestine (anus, rectum, sigmoid, transcending, and ascending colon)

• Moderate sedation

• Diagnostic and/or therapeutic

• Pt lies on left side with legs drawn up towards chest

• Nursing care:

  • Colon cleanse education and med admin

  • Clear liquid or low residue diet

  • Moderate sedation

  • Priority during procedure: ABCs

  • Assess for perforation and hemorrhage

• Therapeutic colonscopy

  • Removal of visible polyps, treat bleeding or area of stricture, bowel decompensation, biopsies

• Contraindications

  • Suspected or confirmed colon perforation, acute severe diverticulitis, acute colitis

GI Intubation: Types and Rationale

Tube feedings have several advantages over parenteral nutrition: they are lower in cost, safer, usually well tolerated by the patient, and easier to use in extended care facilities and in the patient’s home. When possible, the physiological-based preference is the feed the gut

GI Intubation: Rationale - Decompression

Removes gas or fluid from the stomach or intestines to relieve pressure and distention

GI Intubation: Rationale - Levage

Flushes the stomach to remove toxins, blood, or irritants

GI Intubation: Rationale - Med Admin

Delivery of meds directly into the stomach or small intestine when PO isn’t possible

GI Intubation: Rationale - Nutritional Support

Provides enteral feeding when a pt cannot meet nutritional needs by mouth

GI Intubation: Types - Nasogastric (NG) Tube

Inserted through the nose into the stomach for short-term decompression, feeding, or med delivery

GI Intubation: Types - Nasojejunal (NJ) Tube

Inserted through the nose into the duodenum or jejunum for feeding when gastric assess is not safe or tolerated

GI Intubation: Types - Gastrostomy (G Tube or PEG Tube)

• Surgically placed into the stomach for long-term feeding or med admin

  • Done in endoscopy lab

  • Feedings can be started within several hours of insertion

  • Stoma takes 30-90 days to mature so original tube should not be replaced for at least 30 days following insertion

  • Replacement of tube is done per manufacturer guidelines or PRN for ruptured balloon, fistula formation, stomal tract disruption, or deterioration of tube

  • Tube is changed every 3-6 months

  • Preferred for med and nutrition admin (lasts longer than 4 weeks)

GI Intubation: Types - Jejunostomy (J Tube)

• Surgically placed into the jejunum for long-term feeding when gastric feeding is not appropriate or to decrease aspiration risk when the stomach is not functioning adequately

  • Place in surgery, endoscopically, or radiologically

  • Indications: gastric route is not

  • Lasts 6-9 months

  • Preferred for med and nutrition admin (lasts longer than 4 weeks)

GI Intubation: Types - Single-Lumen Tube (Levin or Dobhoff)

• Used primarily for med admin and enteral feedings because it has one simple channel

• Preferred method for med admin and tube feedings