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Elimination Needs II


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Function of Kidneys
-Regulating acid base
-Regulating electrolytes
-Auto regulation of BP
-Stimulate RBCs
*Increased BP can cause damage to the kidneys
-Specific Gravity
-Clean catch
-24 hour urine
*test kidney fx (creatinine clearance)
*urine needs to refridgerated
*pt should urinate and discard urine at beggining of test
Radiological Studies
-KUB: kidneys, ureters, bladder Flat x-ray
-IVP: intravenous Pyelogram Iodine based dye in kidneys (x-ray)
-Retrograde pyelogram: dye into bladder forced up the ureters (x-ray)
-Cystoscopy: bladder endoscope
-Urodynamic Studies: Bladder and voiding
Altered Urinary Elimination
-Frequency: more than normal
-Urgency: sudden strong urge to void
-Dysuria: painful and difficult
-Nocturia: at night
-Hesitancy: inability to start flow
Urinary Retention
-Inadequate emptying of bladder which leads to urinary stasis
*which can lead to infection
*obstruction: prostate, tumor, stone
*drugs: anticholenergics, antiparkinson
*neurologic: not able to control spincter
Reasons for Catheterization
-Urinary retention
-Incontinence (only in extreme cases)
-Accurate I&Os
Types of Catheters
*In and Out
*Straight: check for residual <50cc good
Urinary Obstructions
-Stones: nephro-lithiasis
-Renal Calculi
-Stones are composed of substances normally found in the urine
*calcium oxylate: most common
*Calcium phosphate
*Uric acid: d/t increased protein
*Struvite: infection stones
-75% of stones are calcium based
Care for Patient with Stones
-Control pain once stone starts to migrate from kidneys
-Straine urine
-Provide hot bath
-Increase fluid intake
Stone Removal
-Extracorpeal shock wave lithotripsy (ESWL): non invasive procedure to break up stone
-Stone Dissolution: infusion of chemolytic solution
-Lithotomy: surgical removal
-Endoscopy: removal through endoscope
Patient Education for Stones
-Prevent the recurrence
-Increase fluids
*limit calcium
*acid ASH: acidify urine (prevents infection); aluminum oxide used in struvite and oxylate
*Alkaline ASH: alkalinize urine to prevent uric acid stones
*decrease protein in diet
Male conditions
-Phimosis: prepuce is constricted in uncircumcised males where the fore-skin is stuck & can't be retracted over the glans; may be d/t poor hygeine
-Paraphimosis: foreskin can not be retracted from behind the glans back over the glans
-Priapism: uncontrolled erection without sexual desire (emergency situation)
Conditions of the Testes
-Cryptorchidism: undescended testicle
-Epididymitis: infection of epidiymis usually from UTI or chlamedia or gonorrhea
-Orchitis: infection of the testicle (mumps may cause)
-Testicular Ca: most common cause of Ca in men age 15-35
*educate men on monthly self-exam
Male Condtions
-Hydrocele: cystic fluid filled mass around the testicle
-Spermatocele: sperm containing cyst
-Varicocele: dilated veins (decrease in sperm production)
-Torsion: twisted spermatic cords and blood vessels
Erectile Dysfunction/Impitence
-Persistnet inability to achieve an erection or erection not significant enough to partake in intercours
-Psychological Causes
-Organic Causes: DM, spinal cord injury, Hypertension, Surgical trauma, medciations (dilantin, sedatives, antihypertensives)
Erectile Dysfunction Treatment
-Oral Meds: viagra, spontane, liritra, sialsis
-Suppository: inserted into tip of penise, MUSE: medicated urethral system for erection
-Injection therapy: caverjet, edex
-Devices: vacuum pump
How Viagra works
-A man takes a Viagra® pill.
-The sildenafil citrate enters his bloodstream and flows throughout his body.
-The sildenafil citrate attaches to the PDE5 enzyme in his penis and disables most of it.
-When the man becomes sexually aroused, the brain sends the normal message to the NANC cells in his penis, which produce nitric oxide as usual.
-The nitric oxide creates cGMP, which starts relaxing the arteries in his penis.
-Since the PDE5 has been disabled, the cGMP in the penis does not break down.
-Instead, it builds up and lets the arteries in the penis fully dilate.
-His penis inflates with blood, and the man gets a full erection.
-Non inflatable (semi-rigid)
*less parts to malfunction
*less expensive
*difficult to conceal
*pump is in scrotum
*more natural appearance
*requires ability to work pump
*more complex surgery
Benign Prostatic Hypertrophy
-Enlargement of the prostate
-As it enlarges it extendes upward into
the bladder and obstruct flow of urine
S/S:fatigue, anorexia, N&V, epigastric
discomfort, and multiple urinary
-Removal of the prostate through the urethra
-Post-op: three way foley irrigation to keep clots from forming
-What to expect:
*mild voiding problems
*retrograde ejaculation
*bladder spasms: BNO (belladonna and opium) given for this
Prostate Cancer
-Increased risk with age
-Cause unknown
-Earyl detection will increase prognosis
*Rectal exam anually starting at 40
*Prostatic Specific Antigen (PSA)
+blood test
+wait 7 days after digital rectal exam is done
+Baseline for normal levels for a person is necessary to get
Prostate Cancer Treatment
-Inhibit male homrones
-Female hormones
*DES, estrogen, lupron
*internally planted and external
*radical prostatectomy
Radical Prostatectomy
-Suprapubic: abdominal incision
-Perineal: impitence common side effect
*increased risk for contamination for last two listed
Urinary Tract Infection
-Lower tract: urethra, bladder
-Upper tract: ureters, kidney
-Ascending: moving upward (can occur d/t no treatment)
-Descending: may be caused by an obstruction
-More common in women
UTI risks
-Catheterized patients
-Pregnant women: urinary stasis or obstruction
-Elderly: hygiene
-Multiple sex partners
-DM: bacteria growth
-Urinary stasis (enlarged prostate)
-Poor Hygiene
UTI Treatment
-Take all antibiotics ordered
-Encourage fluids (2L)
-Acidify urine (cranberry juice)
-Educate/practice proper hygiene
-Empy bladder before and after intercourse
-Void at first urge
-Avoid coffee, tea, alcohol
Gstro-Intestinal System
Diagnostic Tests
-Upper GI: x-ray procedure, swallow barium
-Barium enema
-Motor disorder
-Absent or ineffective peristalsis
-Failure of the lower esophageal sphincter (LES) or cardia sphincter
*pain with swallowing
*food sticking to the back of the mouth
*symptoms increase with stress
Gastro-Esophageal Reflex Disease (GERD)
-Backwards flow of stomach contents into the esophagus causing pain and irritation
-Associated with hiatal hernia
*dysphagia (most common)
*acid regurgitation
*pain relieved when standing
GERD treatment
-Dietary management
*small frequent meals
-avoid hot and cold foods
-avoid high fat foods
-avoid nicotine
-do not lie down after eating
-elevate head of bed
Hiatal Hernia
-Protrusion of an upper portion of the stomach through an area of weakness in the diaphragm
-More common in women
*heartburn 30 minutes after a meal
*substernal pain
*feeling of abdominal fullness
*50% of patients who have it don't have symptoms
Hiatal Hernia Treatment
*Hot and spicy foods
*Ingestion of large meals
*apparel that is constrictive
*Twisting, bending, lifting
*Alcohol and nicotine
*Limit carbonated beverages
-do not lie down after a meal and elevate HOB
-Antacids and H2 blockers
*Nissan fundoplication (best results)
*Hill and Belsey procedure
*Chick Angel Device (old)
-Inflammation of the gastric mucosa
-Caused by: NSAIDs, ASA, Digoxin, Spicy foods
-Symptoms: anorexia, nausea, belching, vomiting, epigastric tenderness, + blood in stool
-Treatment: small frequent meals, bland diet, avoid high fat foods, avoid nicotine
-Antacids and H2 blockers
-Antacids: neutralize or reduce acidity
*examples: maalox, tums, gaviscon
-Laxatives: remedies that move the
*stool softeners: facilitate mixing h20
in stool; colace DSS
*bulk formers: absorb water and
increases fecal bulk; metamucil
*surfactants: increases slipperiness of
colon; oil retention enema
*contact laxative: stimulates
peristalsis through mucosal irritation;
*osmotic: retains water in feces;
lactulose, golytely, MOM
-Inflammation of the veriform appendix
-7% of population
-Most common in 10-30
*right upper quadrant pain
*acute pain at McBurney's point with rebound tenderness
*Rigidity of abdomen
*+ Rovsings sign (when left side palpated pain is felt in right side)
*Increased WBC
Appendectomy Pre-op
-Hold analgesic until diagnosis has been comfirmed
-NO enemas or cathartics (laxatives)
-Surgery ASAP to prevent rupture
Appendectomy Post-op
-NG post-op: open classic method
-Semifowlers position
*Until bowel sounds return/passing gas
-Complications include:
*paralytic ileus
Intestinal Obstruction
-When normal peristalsis does not take place
-Nutrients do not move through GI tract
-Digestion and absorption is inhibited
-Potenially life threatening
-Mechanical of functional
-Intussusception: one portion of the bowel slides into the next
-Volvulus: the rotation or twisting of a loop of intestine around itself
-Paralytic ileus
*common after surgery
*absent bowel sounds
*abdominal distention
-Mesenteric infarction
*blood clot causes interrupted blood supply
*acute pain
GI Manifestations
-Bulk (metamucil): absorbs water and increases fecal bulk
-Stimulant (dulcolax): stimulates peristalsis through mucosal irritation
-Stool softener (colace): facilitates the mixing of water into stool
-Osmotic (milk of magnesia): retain water in the feces
Naso-Gastric Tubes
-Reasons for them:
*Gastric decompression
*Delivery of food or meds
*Levin: single lumen
*Sump: air port for suction
*Enteroflex: flexible, weighted tip
Gastric Tube Types
-Gastrostomy: percutaneous to stomach
-Jejunostomy: percutaneous to jejunem
-Percutaneous Endoscopic Gastrostomy (PEG)
*placed by endoscopy
Care of patient with NG tube
-Good oral care
-Keep patient in semi-fowler's position
-Check tube for migration
-check placement
*Q shift and before giving meds or intrermitten bolus
-Flush (irrigate tube)
*before and after instilling meds/feedings
*check residual Q 4 hours (should be <30cc)
*Hold feedings if >150cc
*weigh patient
*Accurate I&Os
*Assess lab values indicating fluid balance
*Change bad and tubing Q 24 hours
Enteral Feedings
*meets nutritional needs and keeps blood flow to GI tract
*Well tolerated by patients
*Low cost
*Discourages bacterial growth in GI tract
*tube obstruction
*abdominal distention
*Dumping syndrome
Dumping Syndrome
-Rapid emptying of the stomach contents into the small intestine
*characterized by sweating & weakness
-Usually happens when a person is first put on tube feedings
-Formula's high osmolarity causes cells to become dehydrated
Malabsorption Disorders
-Diseases of the small intestine are the most common cause of malabsorption
-Categories of malabsorption:
*Mucosal (transport)
*Infectious diseases
*Luminal problems
*Disorders that cause malabsorption of specific nutrients
-Lactose intolerance: limit lactose intake
-Gluten Intolerance
*S/Sa: steatorrhea: the presence of greater than normal amounts of fat in the feces which are frothy and foul smelling and floating; a symptom of disorders of fat metabolism and malabsorption syndrome
*Sprue: tropical organism (weight loss, diarrhea, anemia)
*Celiac disease: intolerance of gluten (rice, corn, soy)
Cholelithiasis (gallstones)
-Calculi formation in the gallbladder
*stones are solid consituents of bile
*most prevalent after age 40
*by age 75 one in three people will have gallstones
-Endoscopic Retrograde Cholangio pancreatography
-Inflammation/infection of the gallbladder
-Usually caused by gallstones
-Cause unknown
-Risks (5 f's)
*Fertile (oral contraceptive)
Cholecystitis Signs & symptoms
-May be assymptomatic
-Episodic right upper quad pain radiating to the back
-Intolerance to fatty foods
-Pale, clay colored stools
-Pruritis associated with jaundice
Cholecystitis Treatment
-Medications (chenodeoxycholic acid) to dissolve the gallstone
-Dietary management
-Non surgical removal
*Endoscopic stone retrieval
-Surgery (endoscopic or open)
Laparoscopic Cholecystectomy
-Four small pin-like incisions
-Abdomen filled with CO2
-Gallbladder placed in a bag
-Removed through the incisions
-Minimal complications
Open Cholecystectomy
-Surgical incision
-Gallbladder removed
-More complications
*used to maintain patency of CBD until edema subsides
*drains the bile made by the liver
*monitor output-expect large output in first 24 hours
24 Hour Urine Collection
-Measures urine output and urine
constituents for a 24 hour period
-Patient voids at beginning of test
and discards that void
-All subsequent voids are measured and
documented and refigerated for a full
24 hours
Small Intesting Absorption
-Duodenum: iron and calcium
-Jejunum: fat, protein, carbs, sodium,
and chloride
-Ileum: B12 and bile salts
-Upper right quadrant
-Stores and filters blood
-Secretes bile and metabolizes sugar
-Reservoir for bile
-Bile helps alkalinize intestinal
contents and absorbs and digests fats
-Emesis, urine, feces
-Testing for blood in excretions of GI or GU tracts
-Blood Urea Nitrogen
-Normal values: 5-20mg/dl
-Testing for glomerular function of in
the kidneys
-BUN increases with decreased kidney
function, GI bleed, dehydration, fever,
sepsis, increased protein intake
-BUN decreases with end-stage liver
disease, decreased protein intake,
starvation, conditions resulting in
expanded fluid volume (pregnancy)
-Normal values: 0.7-1.5mg/dl
-Creatinine is an end-product of
muscle metabolism
-Concentrations are dependent on lean
muscle mass
-Creatinine increases when renal
function decreases
Serum Bilirubin
-A yellow bile pigment found as sodium
bilirubinate (soluble), or so an insoluble calcium salt in gallstones
-Formed from hemoglobin during normal and abnormal destruction of erythrocytes by the reticuloendothelial
-Normally small amounts in blood
-It is seen in conditions where there
is excessive destruction of RBC or
interference of mechanisms of
excretions in the bile
Gastro-Intestinal Diagnostic Tests
-C:consent form
-W:vital signs
This is a test for visualization of the
GI tract from the mouth to the duodenum
-Pt should limit food/liquid intak for
24-72 hours before procedure
-18 hours before procedure pts drink
golytely to stimulate evacuation of
-Laxatives and enemas may also be
-Routinely done at age 50 then every
5-10 years after that
-After procedure nurse monitors for
rectal bleeding and signs of intestinal
perforation (fever, rectal drainage,
abdominal distention, and pain)
Oral Cholecystogram
-Radiographic record of gallbladder
structure and function after oral
administration of a contrast medium
Intravenous cholangiogram
-Record of the visualization of the
gallbladder and bile duct
-Contrast medium is injected
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
-Examinatin of the hepatobiliary system
-Carried out via a fiberoptic endoscope
-Inserted into the esophagus to the
-Glucagon or anticholinergics may be
given eliminate duodenum peristalsis
Urinary Incontinence
-Stress: involuntary loss through
increase in intra-abdominal pressure
r/t coughing, sneezing, or position
change; effects child bearing women
-Urge: pt is aware of need to urinate
but is unable to reach toilet in time
-Overflow: overdistention of the
bladder; seen in neurologic
abnormalities, tumors, or obstructions
-Reflex: absence of normal sensations
r/t spinal cord injury
-Functional: severe cognitive or
physical impairment make it difficult
for pt to identify need to void
Urine Retention
-The inability to fully empty the
-Can lead to overflow incontinence
-Can occur post-op especially if
surgery affected the perineal or anal
-General anesthesia also reduces
bladder muscle intervention
-S/S:pain, restlessness, chilling, flushing, headache, diaphoresis,
increase in BP
Measuring Risidual Urine
If the scanner measures more than 100mL
of urine after the pt voids, then a
catheterization should be performed to
reduce risk of UTI and bladder
Nursing care for pt with cath
-insertion is sterile
-maintain closed drainage
-tape catheter tubing securely
-keep collection bad lower than bladder
-good pericare
-monitor I&Os
-encourage fluid intake
empty bag Q8hours or PRN
-After removal, monitor for return of
bladder function
Suprapubic Catheter
-Catheter or tube placed into the
bladder through a suprapubin incision
-Trial voiding: catheter is clamped for
4 hours and pt attempts to void
*catheter is unclamped and residual
measured, if <100ml (twice, am and pm)
then Suprapubic cath. is usually
*if not it is changed Q6-12 weeks
-Psychogenic: anxiety, fatigue, stress,
depression, pressure to perform
-Organic: occlusive vascular disease,
endocrine disorders, trauma, alcohol,
medications, and drug abuse
Nursing care of pt with renal calculi
-pain relief
-hot baths or moist heat to flank area
-Fluids are encourage
-Diet restriction:
*protein < 60g/day to decrease urinary
excretion of calcium and uric acid
*Sodium <3-4g/day
*low calcium
*restrict oxalate containing foods:
spinach, strawberries, rhubarb, tea,
-Urine is strained to catch stones
Risk factors of organic impotence
-decreased sex hormone production
-neurologic damage
-decreased arterial blood flow
-prostate cancer
-urologic dysfunction
Nursing care of pt s/p radical
-Strict I&Os
-S/S of F&E imbalance must be monitored
for (>bp, confusion, resp. distress)
-ambulation soon after surgery to
asses pain
-assess bladder for irritability,
-encourage walking but not sitting for
long periods of time
-no excessive straining
S/S of UTI in elderly
-Altered sensorium
-New incontinence
-Low grade fever
-Generalize fatigue
-Change in cognitive function
Urinary Antiseptics
-Levaquin: bacterial DNA synthesis
-Macrobid: bacterial enzymes, should
not be used in people with renal
S/S of Intestinal Obstruction
-Crampy wave-like, colicky pain
-pt may pass blood and mucus but no
fecal matter and no flatus
-intense thirst
-vomiting of fecal matter
-Hypovolemic shock
Nurse reports: I&O imbalances,
worsening pain, abdominal distention,
increased NG output
Meds: reglan, compazine, phenergan
Purposes of GI Intubation
-to decompress the stomach
-remove gas and fluid
-lavage the stomach
-remove ingested toxins
-dx disorders of GI motility
-admin medications and feedings
-treat an obstruction
-aspirate contents for analysis
Complications of NG Tube Feeding
-Diarrhea (most common)
-gas, bloating, cramping
-aspiration pneumonia
-tube placement
-tube obstruction
-nasopharyngeal irritation
-Dehydration and azotemia (excessive
urea in the blood)
-tube feeding syndrome: excessive urea
and dehydration

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