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Urge incontinence

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The involuntary loss of larger amounts of urine accompanied by a strong urge to void. It is often referred to as OVERACTIVE BLADDER.

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Stress incontinence

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An involuntary loss of small amounts of urine with increased intra-abdominal pressure. Activities that produce leakage of urine include exercise, laughing, sneezing, coughing, and lifting.

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Functional incontinence

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The untimely loss of urine when no urinary or neurological cause is involved. This type of incontinence occurs because of physical disability, immobility, pain, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet.

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Mixed incontinence

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A combination of urge and stress incontinence.

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Transient incontinence

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Short-term incontinence that is expected to resolve spontaneously. Causes include UTI and medications, especially diuretics.

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Overflow incontinence

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The loss of urine in combination with a distended bladder. Causes of Overflow Incontinence include fecal impaction, neurological disorders, and enlarged prostate.

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Unconscious (reflex) incontinence

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Loss of urine when the person does not realize the bladder is full and has no urge to void. Central nervous system disorders and multi-system problems are common causes.

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Enuresis

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Bed-wetting. Unintentional passage of urine.

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Presentations of enuresis

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Wet sheets Wet clothes Room smells of urine

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Nursing interventions for enuresis

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Bladder training Estabish toileting schedule Monitor and increase fluid in AM, decrease in PM Teach Kegel exercises Teach incontinence diary Avoid caffeine and alcohol Provide incontinence care

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Urinary retention

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An inability to empty the bladder completely. Etiologies include obstruction (BPH), inflammation and swelling, neurological problems, medications (anesthesia & opiods), and anxiety. Treatments: Urinary catheterization.

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Nursing interventions for urinary retention

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Prevent UTI's Prevent backflow of urine Encourage fluids Perineal hygiene

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Urinary tract infection (UTI)

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An infection involving the kidneys, ureters, bladder, or urethra. Often caused by E.Coli. A UTI is labeled according to the region of infection. In general terms, reference is made to lower urinary tract (e.g., urethra, bladder, or prostate) and upper urinary tract infections (e.g., ureters or kidney).

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Symptoms of upper UTI

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-Fairly high fever (higher than 38.3° C [101° F]) -Shaking chills -Nausea -Vomiting -Flank pain

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Symptoms of lower UTI

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Dysuria Frequency Urgency Hesitancy Cloudy, foul smelling urine Hematuria Bladder spasms Lower abdominal pain Mild fever (less than 38.3° C [101° F]) Chills Not feeling well (malaise) OLDER ADULTS will appear confused, have a loss of appetite, (hypotension, tachycardia, tachypnea, and fever are symptoms of urpsepsis)

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Nursing interventions for UTI

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Promote fluid intake up to 3 liters daily Administer antibiotics as prescribed Encourage to urinate every 3-4 hours Encourage to shower daily Recommend warm sitz bath for comfort Avoid use of indwelling catheters Advise to urinate before and after sex Advise to drink cranberry juice to reduce risk

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Interstitial cystitis

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Presentations of I.C. include: Urgency Frequency Nocturia Dysuria Hematuria may be present All of these with no evidence of infection! Pain: Pain ranges from mild to severe. Pain is most prominent as the bladder fills between voiding. Suprapubic pain is a common finding, but a person may also feel pain in the bladder, the urethra, the area below the umbilicus, the lower back, or the area around the vagina. Men may also feel pain in the scrotum, testes, or penis. Pain can come and go or it can be constant. It can increase during sex, and some women find that it is worse when they are having their period.

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Pyelonephritis

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An infection of the UPPER urinary tract. It may involve the ureters, renal pelvis, and papillary tips of the collecting ducts. Unchecked, it can extend into the tubules of the nephron, creating a potential for renal failure. Filtration, re absorption and secretion are impaired.

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Symptoms of pyelonephritis

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-Bacteruria -Flank pain at the costovertebral angle (CVA) -Fever -Chills -Colicky abdominal pain -Nausea -Vomiting -Dysuria -Frequency -Nocturia

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Diagnostic tests for pyelonephritis

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Urinalysis and urine culture may be sufficient in mild, initial cases of pyelonephritis in an uncomplicated presentation. Computed tomography (CT) is the standard diagnostic tool for pyelonephritis unresponsive to 72 hours of antibiotic therapy. Ultrasound is used when CT scanning is contraindicated, such as in pregnancy or in pre-existing renal compromise.

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Nursing interventions for pyelonephritis

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Assess and monitor: Nutritional status I&O Fluid & Electrolytes BUN/Creatnine WBC's Temp Pain Increase fluid intake to at least 2L/day Administer acetaminophen for fever Administer opiods for pain Assist with hygiene

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Glomerulonephritis

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Inflammation of the glomerular capillaries. In patients with glomerulonephritis, the glomeruli become inflamed and impair the kidney's ability to filter urine. Eventually, the glomeruli become inflamed and scarred, and slowly lose their ability to remove waste and excess water from the blood to make urine. Immune complex disease - NOT AN INFECTION

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Symptoms of glomerulonephritis

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Anorexia Oliguria Brown, tea, or cola-colored urine Proteinuria Dysuria SOB Orthopnea Crackles S3 heart sound Periorbital edema Mild hypertension Changes in LOC Weight gain Flank pain --This cluster of symptoms—hematuria, edema, and hypertension—is known as nephritic syndrome. Approximately 95% of patients with post-streptococcal glomerulonephritis have at least two of these symptoms; 40% have all three.

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Diagnostics for glomerulonephritis

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-Laboratory tests include: -CBC -Electrolytes -BUN & creatinine (will be elevated) -GFR (will be decreased) -Urinalysis -Cultures of the throat and skin to rule out Streptococcus

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Nursing interventions for glomerulonephritis

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Administer antibiotics as prescribed Monitor blood pressure Monitor fluid and electrolytes Maintain low sodium diet (2g per day) Fluid restrictions (1L per day) Monitor I&O Possible loop diuretics with severe edema Possible ACE inhibitor or calcium channel blocker

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Nephrotic syndrome

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Not a single disease but a group of symptoms. Symptoms include heavy proteinuria, hypoalbuminemia, edema, hypercholesterolemia, and normal renal function. Nephrotic syndrome can be primary or secondary. Primary nephrotic syndrome occurs as part of a recognized systemic disease. Nephrotic syndrome is often described as a disease of children and is relatively rare. It is 15 times more common in children than in adults.

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Manifestations of nephrotic syndrome

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Pitting edema (ankles & legs) Periorbital edema Pleural effusion or ascites Foamy urine Anorexia Irritability Fatigue Abdominal discomfort Diarrhea

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Renal calculi

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Kidney stones. Cause is unknown, but greater incidence in males. Most stones are calcium oxalate but can also be composed of calcium phosphate, uric acid, struvite, and cystine.

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Manifestations of renal calculi

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-Severe pain (renal colic). Pain intensifies as the stone moves through the ureter. Flank pain suggests the stone is located in the kidney or ureter. Flank pain that radiates to the abdomen, scrotum, testes, or vulva suggest the stone is in the ureter or bladder. -Frequency -Fever -Diaphoresis -Pallor -Nausea -Vomiting -Tachycardia, tachypnea, increased BP (pain) -Decreased BP (shock) -Hematuria -Oliguira/anuria occurs with stones that obstruct urinary flow. This is a medical emergency and needs to be treated to preserve kidney function.

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Nursing interventions for renal calculi

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-Increase fluid intake to 3L/day -Administer IV fluids, analgesics and antibiotics as prescribed -Strain all urine to check for passage of stone, and save to send to lab for analysis -Monitor pain, I&O, urinary pH

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Acute renal failure

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Sudden loss of kidney function caused by failure of renal circulation or damage to the tubules or glomeruli. Usually reversible, with spontaneous recovery in a few days to weeks Ischemia is primary cause; it produces irreversible damage to tubules if continues for more than 2 hours.

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Nursing interventions for acute renal failure

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Monitor labs and dialysis Potassium restrictions Fluid reduction Accurate I&O Daily weights Check for edema and lung sounds Energy conservation

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Oliguria

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Urine output of less than 400 mL in 24 hours. For pediatric patients, oliguria is < 0.5-1.0 mL/kg per hour.

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Anuria

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The absence of urine, often associated with kidney failure or congestive heart failure. This term is used when urine output is less than 100 mL in 24 hours.

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Chronic renal failure

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A progressive and irreversible decline in renal function ranging from mild with nearly normal function to ESRD requiring renal replacement therapy. Characterized by a glomerular filtration rate (GFR) less than 20% of normal. Diabetes mellitus and hypertension are the two most common causes of CRF in the United States. The common underlying cause of progression to CRF is glomerulosclerosis. Regardless of the initial insult, glomerulosclerosis is the end result. As the level of glomerular function declines, need for intervention increases.

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Clinical presentations of chronic renal failure

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1. Early: nausea, apathy, weakness, and fatigue; declining urine output 2. Late: possibly frequent vomiting, increasing weakness, lethargy, and confusion 3. Client may report "restless leg syndrome," paresthesia, and sensory loss 4. Personality changes, such as anxiety, irritability, and hallucinations; seizures and coma posible in late stages 5. Respirations may change to Kussmaul pattern, with deep coma following 6. Skin becomes pale and dry, with yellowish hue; metabolic wastes cause itching and uremic frost (crystallized deposits of urea on skin) 7. Urinalysis shows fixed specific gravity approximately 1.010, equivalent to plasma; abnormal proteins, blood cells, and casts are present. 8. Elevated creatinine and BUN and decreased creatinine clearance 9. Abnormal electrolyte values as noted above 10. Moderate anemia 11. Decreased platelets 12. Decreased renal size by ultrasonography 13. Positive renal biopsy if damage caused by cancer

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Nursing management of chronic renal failure

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1. Provide diet low in protein (such as 60 grams protein) with supplemented amino acids; restrict fluids as ordered 2. Provide electrolyte replacement or restriction -Na+ restriction (such as 2 grams daily) -K+ restriction (such as 2 grams daily) -Replacement of bicarbonate stores to treat acidosis 3. Monitor and plan nursing care for hypertension and heart failure 4. Prepare client for dialysis or kidney transplant 5. Monitor I&O and vital signs 6. Monitor laboratory results: BUN and serum creatinine, pH, electrolytes, and CBC 7. Provide symptomatic relief for nausea and vomiting 8. Observe for signs of infection 9. Provide rest periods to combat fatigue, which is chronic in nature 10. Help client learn about and adjust to diagnosis; support coping strategies and work with client to develop realistic goals 11. Medication therapy: limited by kidneys' inability to excrete -Diuretics to reduce volume of extracellular fluid -ACE inhibitors to maintain normal BP -Electrolyte replacement -Phosphate binding agents, such as calcium carbonate -Kayexalate to reduce serum K+ levels

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Uremia

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Excess urea and other nitrogenous waste products in blood.

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Diarrhea

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Increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort, and possibly incontinence.

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Fecal incontinence

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Involuntary elimination of feces, often caused by diarrhea.

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Nursing interventions for fecal incontinence

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Determine cause. Such as medications, infections, or impaction. Provide perineal care after each stool, and apply moisture barrier. Provider can prescribe anal bag or other bowel management system to collect stool and prevent it from coming in contact with the skin.

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Constipation

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A bowel pattern of difficult and infrequent evacuation of hard, dry feces. The number of bowel movements a patient has is individual, but if a patient has fewer than three bowel movements per week or must vigorously strain, the patient is considered to have constipation. It is due to sedentary lifestyle, poor diets (low in dietary fiber and fluid), frequent use of laxatives, pregnancy, and some medications.

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Fecal impaction

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The presence of a hardened fecal mass in the rectum. The impaction often blocks the passage of normal stool and sets up a vicious cycle of furthering hardening.

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Manifestations of fecal impaction

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Liquid stool may leak, seeping around the hardened mass, and the patient may report feelings of fullness, bloating, constipation, diminished appetite, and a change in bowel habits. You can detect fecal impaction by digital examination of the rectum.

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Bowel obstruction

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Significant mechanical impairment or complete arrest of the passage of contents through the intestine. Can be either mechanical (physical or structural) or functional. Most obstructions occur in the small intestine. Most commonly due to postoperative adhesions, fibrous bands within the peritoneum, which may compress the bowel and cause obstruction, or be a focus for a volvulus (a twisting of the bowel on itself that causes obstruction). Prior abdominal surgery or sepsis (e.g., pelvic inflammatory disease, appendicitis) may cause adhesions.

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Clinical presentation of bowel obstruction

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Colicky, mid-abdominal pain often over a period of days. Vomiting occurs early in the course, especially with proximal simple obstruction. A change in the character of the pain (continuous, increasing severity) suggests the development of more ominous ischemic complications. Pain lasting several days, with progressive distension, suggests a more distal obstruction. Patients may report reduced to absent flatus for days preceding presentation and distension. Auscultation typically reveals increased bowel sounds and high-pitched tinkling in early obstruction.

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Nursing interventions for bowel obstruction

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Careful abdominal examination is necessary in suspected obstruction. Palpation should follow percussion, and severe pain is unusual, unless strangulation, ischemia or infarction, or perforation have occurred. In that case, there may be signs suggestive of peritonitis and acute abdomen, including guarding and rebound tenderness. A careful search for inguinal hernias, a rectal exam for masses, and analysis of stool for occult blood conclude the abdominal assessment. Strict bowel rest and careful attention to fluid replacement for loss as well as maintenance, with appropriate laboratory guided electrolyte supplementation (especially potassium), are indicated.

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Irritable bowel syndrome (IBS)

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A relatively common functional disorder characterized by abdominal pain and altered bowel habits in the absence of structural or biochemical explanations for the symptoms. The cause of IBS is unknown, although there may be a genetic propensity to the disorder. In addition, stress exacerbates the manifestations, as does a diet high in fat, irritating foods, alcohol, and smoking.

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Symptoms of IBS

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Recurrent abdominal pain or discomfort at least three days per month in the last three months associated with two or more of the following: 1. Improvement with defecation 2. Onset associated with a change in frequency of stool 3. Onset associated with a change in form (appearance) of stool

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Health promotion and disease prevention for IBS

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Avoid foods that trigger exacerbation, such as dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspertame. Avoid alcoholic and caffeinated beverages, and other fluids containing fructose and sorbitol. Consume 2-3L/day from food and fluid sources Increase fiber intake (approx 30-40g/day)

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Ulcerative colitis

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Edema and inflammation that begins in the rectum and can progress proximally, but is usually limited to sigmoid colon and rectum. Cause is unknown but may be related to stress, genetics, infection, dietary factors (low fiber intake), or antibody formation.

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Symptoms of ulcerative colitis

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Abdominal pain/cramping (LLQ) Anorexia Weight loss Fever Diarrhea Abdominal distention Abdominal tenderness & firmness High pitched bowel sounds Rectal bleeding

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Nursing interventions for ulcerative colitis

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Rest is required to decrease intestinal activity. Diet therapy may include a low-residue, high-protein, high-calorie diet with vitamins and iron; in severe cases NPO to rest bowel; TPN will be ordered in severe cases. Assess dehydration, fluid and electrolytes.

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Appendicitis

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An inflammation of the appendix, which is a small finger-like appendage just below the ileocecal valve. Treatment: Appendectomy is the most common emergency abdominal surgery in the United States.

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Diverticulitis

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Inflamed sac-like pouches of mucosa through the muscular layer of the bowel that may occur anywhere along the GI tract. Can lead to bleeding (5%), abscess and fistula formation, perforation, and/or obstruction.

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Crohn's disease

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Chronic inflammatory bowel disorder with a relapsing and remitting course. Once remission is achieved, the main aim of the management of Crohn's disease is maintenance of that remission. Usually begins with a small inflammatory lesion of the intestinal mucosa. Eventually, the inflammation continues and progression through all layers of tissue is seen. Deeper ulcerations, fissures, and granulomatous lesions persist into the deeper layers of the bowel wall. As the disease progresses, the inflammation causes the bowel wall to thicken and become fibrotic, and a narrowing of the intestinal lumen occurs. Fistulas are common between loops of bowel, as are adhesions of the diseased bowel areas. The absorption of nutrients is impaired as the jejunum and ileum are affected.

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Clinical presentations of Crohn's disease

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Typically, abdominal pain (RLQ) and tenderness accompanies the disorder. Often the pain is relieved temporarily with defecation. In addition, eating can initiate the abdominal discomfort, and patients may consequently limit their food intake. This lends them to have nutritional deficits, and weight loss, and experience malnutrition and even secondary conditions. Diarrhea is common and not necessarily positive for occult bleeding. There may be a palpable mass in the RLQ. Steatorrhea is also a common finding with the stool (pale appearance, presence of fat and mucous)

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Nursing interventions for Crohn's disease

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Provide prescribed diet: usually high-calorie, high-protein; involve client in making appropriate menu choices. Weigh daily, maintain calorie count, and monitor I&O. TPN may be ordered during periods of severe exacerbation to provide total bowel rest.

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Gastroenteritis

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An increase in the frequency and water content of stools and vomiting as a result of inflammation of the mucous membranes of the stomach and intestines, primarily affecting the small bowel. May be viral or bacterial in origin.

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Symptoms of gastroenteritis

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Onset of diarrhea w/ accompanying abdominal cramping or pain Nausea and vomiting Bloody, mucous, or watery, foul smelling stool Possible fever Dehydration Positive stool sample for bacteria

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Treatment for gastroenteritis

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Fluid replacement Diet therapy Drug therapy (antiemetics or anticholinergics) Antimicrobials are given if it is caused by an infecting organism susceptible to therapy

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Patient education for gastroenteritis

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Replace fluids Follow recommended diet Wash hands Do not share utensils Maintain clean bathroom

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Consequences of fecal or urinary incontinence

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Skin breakdown Changes in daily activities Changes in social relationships

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Elimination

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Excretion of waste from the body

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Bowel elimination

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Passage and dispelling of stool through the intestinal tract by means of intestinal smooth muscle contraction.

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Urinary elimination

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Passage of urine out of the urinary tract through the urinary sphincter and urethra.

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Populations at greatest risk for problems with bowel and urinary elimination

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Children Pregnant women Older adults

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Renal ultrasound (kidney scan)

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A renal ultrasound visualizes the parenchyma and associated structures, including the renal blood vessels, using sound waves to produce an image. The nurse's role during a renal ultrasound is to primarily make sure the patient has received the proper education and is prepared for the procedure guidelines for patient education.

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Patient education for renal ultrasound

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The nurse can assist and educate the patient undergoing a renal ultrasound by providing the following information: -You will be positioned in a supine position. Your flank will be exposed and appropriately draped. -Your abdomen will be lubricated with an acoustic gel. -You will be asked to take a deep breath and hold it. This is done so that various parts of the kidney can be visualized. -The technician will use a transducer to visualize various regions of the kidney and surrounding areas.

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Renal biopsy

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Removal of a piece of kidney tissue for microscopic evaluation. The least intrusive method to obtain samples of the renal cortex. Pre-procedure, the patient will be instructed not to eat or drink for four to six hours. The patient should be forewarned of the approximate two-hour period of bedrest required for transplant graft biopsy and the four to six hours of bedrest for native kidney (one's own kidney as opposed to a transplant graft) biopsy. Less bed rest is required for transplant biopsy due to less strain on the renal capsule with the graft located in a lower abdominal quadrant.

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Post-procedure patient education for renal biopsy

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Frequent vital signs and inspection of the biopsy site for hematoma. Typical frequency is every 15 minutes during the first hour. Then, gradually the interval is increased if no bleeding occurs. Monitor for any evidence of bleeding. Signs and symptoms include significant change in blood pressure, tachycardia, nausea or vomiting (often associated with hypotension), or a reduction in hematocrit. Anything more than minimal pain is a warning symptom and the patient should be thoroughly assessed. Ureteral colic could signal a clot occluding the ureter. Back pain may indicate a retroperitoneal or intrarenal bleed. Monitor the urine for hematuria or clots. Serial samples of urine are saved in urinalysis tubes, dated, timed, and placed in a rack for color comparison. Educate the patient to avoid heavy lifting for approximately of two weeks and to notify the health care provider of flank pain, light-headedness or dizziness, rapid pulse, dysuria, or hematuria.

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Cystoscopy

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Direct visualization of the urethra, bladder, and ureteral orifices by insertion of a scope. May be used to obtain biopsies and treat pathology of visualized areas.

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Nursing management for cystoscopy

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The patient must avoid food and fluids for four to eight hours prior to the procedure if receiving general anesthesia. Postprocedural care includes monitoring the patient for urinary obstruction secondary to swelling and hematuria related to biopsy or inadvertent injury to urinary structures. Light hematuria and pain during the first void may not be abnormal depending on the extensiveness of the procedure. The patient should be educated to notify the nurse for problems voiding, gross hematuria, excessive pain, fever or chills, and continued dysuria.

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Intravenous pyelogram (IVP)

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Evaluates renal function by analyzing flow of contrast over time. A radiopaque contrast agent is injected intravenously. This renders the urine radiopaque as the contract agent is excreted in the urine. Abnormalities of the lumen, calculi, and masses can be detected. It is imperative to check for dye allergies and to hydrate the patient for posttest dye excretion to avoid nephrotoxicity.

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KUB (Xray of kidneys, ureters, and bladder)

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The KUB shows kidney size, shape, and position and the presence of calculi. Hydronephrosis, cysts, and tumors may be visualized. Constipation can interfere with the viewing field.

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Colonoscopy

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Provides direct visualization of the rectum, colon, entire large intestine, and distal small bowel. A flexible scope is inserted through the rectum and advanced to the cecum. Useful in detecting lower GI disease. Positioning: LT side with knees to chest Anesthesia: Moderate sedation (Midazolam, fentanyl, and/or propofol)

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Nursing management for colonoscopy (Prep)

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-Bowel Prep (laxatives, such as bisacodyl and polyethyline glycol) -Polyethyline glycol isn't recommended for older adults as it can cause fluid and electrolyte imbalances -Polyethyline glycol can also inhibit the absorption of some medications. Review medications and consult with doctor. -Clear liquid diet, NPO after midnight -Patient must avoid medications such as aspirin, anticoagulants, and antiplatelets.

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Nursing management for colonoscpy (Post-procedure)

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-Notify provider of severe pain (possible perforation) -Monitor for rectal bleeding -Monitor vitals & respiratory status. Maintain open airway until patient is awake -Resume normal diet as prescribed -Encourage increased fluid intake -Instruct that there can be some flatulence due to air instillation during the procedure -Do not drive or use equipment for 12-18 hrs after

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Esophagogastroduodenoscopy (EGD)

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Insertion of endoscope through the mouth into the esophagus, stomach, and duodenum to identify or treat areas of bleeding, dilate an esophageal stricture, and diagnose gastric lesions or celiac disease. Position: LT side laying with head of bed elevated Anesthesia: Moderate sedation per IV access. Topical anesthetic to depress gag reflex, atropine to decrease secretions. Prep: NPO 6-8 hrs.

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Nursing management for EGD (Post-procedure)

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-Monitor vitals and respiratory status. Maintain open airway until patient is awake -Notify provider of any bleeding, abdominal or chest pain, and any evidence of infection -Withhold fluids until return of gag reflex -D/C IV therapy when patient tolerates oral fluids w/o nausea and vomiting -Do not drive or use equipment for 12-18 hrs after -Use throat lozenges if sore throat or hoarse voice persists following procedure

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Barium swallow (esophagraphy)

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A fluoroscopic visualization of the esophagus following the ingestion of barium sulfate. The results of barium studies can reveal congenital abnormalities; lesions; spasm; reflux, stricture, and obstruction; inflammation; ulceration; varices; and fistula.

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Patient prep for barium studies

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-Patient should not smoke for 24 hours prior to the procedure (smoking causes an increased production of gastric juices) -Placing the patient on NPO status after midnight -Administering a laxative the evening before and enemas the morning of the test -Educate patient that during the procedure (which will last approximately two hours), pictures will be taken at 30-minute intervals with the patient in different positions -Post-procedure barium will be expelled in the stool, making it milky white. Fluids are forced to help with the excretion of barium. If the barium is not completely excreted, it can cause intestinal obstruction. -Follow up two to three days post-procedure to ensure the patient has had a normal brown stool

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Barium enema

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A rectal infusion of barium sulfate. Is the roentgenographic study of the lower intestinal tract. The colon should be free of all fecal material to allow for maximum visualization

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Clinical management: Primary prevention

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Hydration Adequate dietary fiber Regular toileting practices Regular exercise Avoidance of environmental contamination

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Clinical management: Collaborative interventions

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Treatment strategies depend on the underlying condition The most common strategies include: Pharmacotherapy Incontinence management Invasive procedures and surgery

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Process of micturition (voiding of urine)

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Filling of bladder --> 200-450 mL of urine Activation of stretch receptors in bladder wall Signaling to the voiding reflex center Contraction of detrusor muscle Conscious relaxation of external urethral sphincter

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Lifespan considerations related to urination (infants)

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15-60 mL per kg Produce 8-10 wet diapers per day No voluntary control

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Lifespan considerations related to urination (children)

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Toilet training requires: -Mature neuromuscular system -Adequate communication skills Problems include: -Enuresis -Nocturnal enuresis

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Lifespan considerations related to urination (older adults)

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Kidney function decreases Urgency and frequency common Loss of bladder elasticity and muscle tone leads to: -Nocturia -Incomplete emptying

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Factors Affecting Urinary Elimination

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Personal Sociocultural Environmental Nutrition Hydration Activity level Medications Surgery and anesthesia

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Pathological conditions affecting urinary elimination

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Bladder/kidney infections Kidney stones Hypertrophy of the prostate (male) Mobility problems Decreased blood flow through glomeruli Neurological conditions Communication problems Alteration in cognition

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Nursing management for urinary incontinence

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Prevent skin breakdown Encourage/teach lifestyle modifications Implement bladder training Encourage client to perform Kegel's exercises Use anti-incontinence devices as needed Strategies to promote independent urination Pharmacological interventions Surgical interventions Parental teaching for enuresis

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Consequences: Urinary retention

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Cause: External sphincter does not open for release of urine or blockage of urethra -Leads to increased urine volume and bladder distention -Backflow to the upper urinary tract -Dilation of the ureters and renal pelvis -Pyelonephritis and renal atrophy

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Managing urinary retention

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Urinary Catheterization: Introduction of a sterile tube into the bladder -Straight catheter -Indwelling catheter: Foley -Suprapubic catheter

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Nursing care for urinary catheter

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Prevent urinary tract infection Prevent backflow of urine Encourage fluids Perineal hygiene

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Process of defecation

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Defecation: process of elimination of waste Feces: semisolid mass of fiber, undigested food, inorganic material, etc. -Fecal material reaches rectum -Stretch receptors initiate contraction of sigmoid colon/rectal muscles -Internal anal sphincter relaxes -Sensory impulses cause voluntary "bearing down" -External sphincter relaxes

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Factors affecting bowel elimination

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Developmental stage Personal factors Sociocultural factors Nutrition/hydration Medications Procedures Pregnancy Pathological conditions Bowel diversions -Ileostomy -Colostomy

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Nursing management of diarrhea

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-Monitor stools to quantify diarrhea -Assess and monitor for fluid imbalance -Monitor for alterations in perineal skin integrity -Proper dietary teaching *Clear liquid *Bananas, rice, applesauce, toast (BRAT) *Foods to avoid -Antidiarrheal medications ***Not recommended for acute diarrhea Lomotil, immodium -Teach clients about over-the-counter aids

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Nursing management of constipation

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-Increase intake of high-fiber foods -Increase fluid intake -Increase activity/exercise -Provide privacy -Help client to a position that facilitates defecation -Allow uninterrupted time -Offer laxatives when lifestyle changes are ineffective

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Nursing management of fecal impaction

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-Prevention is the best treatment -Determine presence: digital examination -Enemas *Oil retention to soften *Tap water or Fleet enemas to remove and cleanse -Manual/digital removal: dysimpacting -Establish bowel program to prevent recurrence

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Establishing a bowel training program

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-Plan program with the client -Increase fiber in diet gradually -Increase fluid intake to 8 glasses water per day -Establish a designated time for defecation -Provide privacy for the client -Treatment plan should be staged -Treatment may include stool softener -Modify the plan based on client results

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Nursing management of an ileostomy/colostomy

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-Stoma assessment and care -Strict attention to skin care/peristomal skin assessment -Monitor amount and type of effluent -Be attentive to client's psychosocial needs -Be professional; show acceptance -Attend to odor control -Address client participation in ostomy care ` -Client teaching for home care

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Colostomy

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Brings a portion of the colon through a surgical opening in the abdomen. The location of the colostomy determines the consistency of the feces eliminated, as well as the need to wear an ostomy appliance. The closer the colostomy is to the ascending colon and the ileocecal valve (between the small and large intestine), the more liquid and continuous the drainage will be. In contrast, a colostomy close to the sigmoid colon will produce solid feces.

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Double-barreled colostomy

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Has two separate stomas that externalize the bowel on both sides of the portion that has been removed. The proximal and distal loops are sutured together and both ends are brought out through the abdominal wall. The proximal stoma is the functioning end that drains fecal material. The distal stoma may drain mucus and is sometimes called a mucous fistula.

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Loop colostomy

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Usually performed as an emergency procedure and situated often in the right transverse colon. Consists of a segment of bowel brought out to the abdominal wall. The posterior wall of the bowel remains intact, but a plastic rod is wedged under the bowel to keep it from slipping back into the abdomen. The anterior wall is incised, and the mucosal surface is left visible and open to air. It, too, has a functioning proximal end and limited drainage from the distal end.

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Ileostomy

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Brings a portion of the ileum through a surgical opening in the abdomen, bypassing the large intestine entirely. Drainage at this level is liquid and continuous. The patient must wear an ostomy appliance at all times to collect the drainage.

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Pharmacotherapy for bowel elimination

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-Laxatives *Bulk-forming agents *Bowel stimulants *Lubricants *Saline laxatives -Stool softeners -Antibiotics -Antispasmodics -Analgesics

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Clinical judgement

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An interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response. Related terms: Inference Interpretation Decision Clinical reasoning Critical thinking

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Attributes of clinical judgment

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Involves a holistic view of the patient situation. Is a process orientation (a circular process). Requires reasoning and the interpretation of data.

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Clinical judgment process - Noticing

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A nurse notices things about a patient in the context of the nurse's background and experience, context of environment, and knowing the patient. A nurse is looking for patterns that are consistent with previous experiences and uses that information to guide care.

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Clinical judgment process - Interpreting

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Interpreting is the process of assembling information to make sense of it. Types of reasoning patterns tend to vary with the experience of the nurse: -Novice nurses tend to rely on analytic reasoning. -Expert nurses draw from a variety of reasoning patterns; analytic, intuitive, and narrative.

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Clinical judgment process - Responding

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Responding is the implementation of actions and interventions, based on patient needs. Depending on the level of expertise, the nurse may or may not be able to judge the effectiveness of the intervention before initiating it.

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Clinical judgment process - Reflecting

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Reflecting is the process of thinking and learning from experiences. -Reflection-in-action happens in real time while care is occurring. -Reflection-on-action happens after the patient care occurs. Reflecting is critical for development of knowledge and improvement in reasoning.

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Ethics

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-The study or examination of morality through a variety of different approaches. -How you respond to an ethical situation is a reflection of the core values, beliefs, and character that make you the person who you are and, ultimately, the professional who you will become. -Systematic study of right and wrong conduct. -Formal process for making consistent moral decisions.

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Bioethics

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Ethical questions surrounding biological sciences and technology.

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Clinical ethics

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Decisions made at the bedside.

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Research ethics

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Conduct of research using humans and animals.

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Societal ethics

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Society provides a normative basis for ethical behavior with laws and regulations. Law is the minimum standard of behavior to which all members of society are held.

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Organizational ethics

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Formal and informal principles and values guide the behavior, decisions, and actions taken by members of an organization. Directs all aspects of an organization.

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Professional ethics

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Ethical standards and expectations of a particular profession Held to a higher standard because of privileged role in society Code of conduct Aimed at the highest ideals of practice

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Personal ethics

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Continuously intersect with other categories of ethics. Do not overlap perfectly; consequently, a potential for conflict exists. Sources of ethics are not static and change over time.

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Ethical theory

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Ethics of Duty -Is the right thing to do. Ethics of Consequence -Is the greatest good for the greatest number. Ethics of Character -Is based on life experiences and a willingness to reflect on our actions. Ethics of Relationship -Is the nature and obligation inherent in human relationships.

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Nursing ethics

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Ethical questions that arise out of nursing practice -What will your level of participation be in a given ethically challenging situation? -Can you support clients'decisions based on their ethical beliefs? -What are your feelings about the results of decisions made by others?

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Failure to act or respond in an ethically appropriate way has been linked to:

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Serious and potentially dangerous errors Personal stress Professional burnout

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Ethical decision making

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Health care decisions that present an ethical dilemma are not made by individuals alone. Health care organization's compliance officer and compliance committee are charged with the responsibility of ensuring that ethical standards are met. Institutions have reporting mechanisms for unethical behaviors.

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Ethical issues in nursing

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Protecting patients' rights and human dignity Not respecting informed consent treatment Providing care with risk to the health of the nurse Using or not using chemical or physical restraints Understaffing Prolonging the living and dying process with inappropriate measures Policies that could threaten the quality of care Working with unethical or impaired colleagues

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Morals

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Private, personal, or group standards of right and wrong Moral behavior; in accordance with custom; reflects personal moral beliefs

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Moral distress

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Occurs when the nurse is aware of the right and moral action to take in a given patient situation but is unable to carry out that action because of external constraints. Perceived constraints : -Physicians; nurse administrators; other nurses -The law; threat of lawsuit

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Moral outrage

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Belief that others are acting immorally. Similar to moral distress, except that in cases of moral outrage, nurses do not participate in the act. Therefore, they do not believe that they are responsible for doing wrong, but that they are powerless to prevent the wrongdoing. Powerlessness Cannot prevent a "wrong" Respond with "whistleblowing"

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Whistleblowing

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Identification of an unethical or illegal situation Can involve one person or an entire organization Reporting such an action to someone in authority Need accurate information Be aware of the consequences ANA working to protect whistleblowers

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Factors in moral decision making

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Values -Belief about the worth of something -Highly prized ideals, customs, conduct, goals -Freely chosen -Learned through observation and experience -Vary from person to person Attitudes -Feelings toward person, object, idea -Includes thinking and feeling component -What a person thinks Beliefs -Something that one accepts as true -Not always based on fact

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Consequentialism

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The rightness or wrongness of an action depends on the consequences of the act rather than on the act itself. Theories of this type are also called: Teleology- from the Greek word telos, meaning "end" or the study of ends (also called final causes) . Utilitarianism- the most familiar consequentialist theory, takes the position that the value of an action is determined by its usefulness. The principle of utility states that an act must result in the greatest good (positive benefit) for the greatest number of people.

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Deontology

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Unlike the utilitarian model, considers an action to be right or wrong regardless of its consequences.

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Formalism

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Defines morals based off of logic and reason which says that if something is defined as wrong or right, it is defined as wrong or right all the time.

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The categorical imperative

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One should act only if the action is based on a principle that is universal—or in other words, if you believe that everyone should act in the same way in a similar situation.

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Feminist ethics

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Based on the belief that traditional ethical models provide a mostly masculine perspective, and that they devalue the moral experience of women. Uses relationships and stories rather than universal principles. Addresses female perspective of issues.

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Ethics of care

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Nursing's responsibility to care in ethical situations. Using an ethics of care perspective, nurses include a responsibility to care as a part of their professional behavior. Some aspects of care include the ability and duty to appreciate, understand, and even share the patient's pain or condition.

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Professional guidelines for ethical decision making

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Nursing Codes of Ethics International Council of Nurses American Nurses Association Standards of Care Patient Care Partnership

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Autonomy

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Patients have the freedom to make decisions for themselves.

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Non-maleficence

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To do no harm, either intentional or unintentional

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Beneficence

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To act in the best interest of others; to benefit others

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Fidelity

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Duty to keeping commitments and promises

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Veracity

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To tell the truth, which has an added benefit of promoting trust between client and nurse.

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Justice

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Fair, equitable, and appropriate treatment; resources are distributed equally to all.

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Evidence based practice

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Knowledge bases for clinical decisions Definition: -Research evidence -Clinical expertise -Patient preference Sociopolitical forces in quality of care EBP is using the best research and proven assessments and treatments in our day-to-day clinical care and service delivery. Why it is important to patient care: The patient gets up-to-date care that has already been done in studies.

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Major features of EBP

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Interdisciplinary Evidence summary Translation to clinical practice guidelines Provider and organizational factors guide integration Evaluation

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ACE Star Model of Knowledge Transformation

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The core concept of the ACE Star Model is knowledge transformation; this is defined as the conversion of research findings from primary research results through a series of stages and forms to have an impact on health outcomes by way of evidence-based care. Each of the five points of the star focuses on a sequential cognitive activity. In the model the stages progress clockwise from discovery to evaluation.

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Star point 1: Discovery

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Primary research. It is the approach with which nurses are familiar, i.e., single reports of research studies.

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Star point 2: Evidence summary

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All primary research on a given clinical topic is gathered and summarized into a single statement about the state of the science.

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Star point 3: Translation

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Experts are called on to consider the evidence summary, fill in gaps, and merge research knowledge with expertise to produce clinical practice guidelines (CPGs). Clinical practice guidelines are commonly produced and sponsored by a clinical specialty organization. The aim of translation is to provide a useful and relevant package of screened, summarized, and interpreted evidence to clinicians and patients in a form that suits the time, cost, and care standard.

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Star point 4: Integration

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Perhaps the most familiar stage of knowledge transformation in health care because of society's longstanding expectation that health care be based on the most current knowledge, thus requiring implementation of innovations. Once guidelines are produced, implementation plans are put into action to change the individual clinician practices, organizational practices, and environmental policies.

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Star point 5: Evaluation

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A broad array of endpoints and outcomes are evaluated. These include evaluation of the impact of EBP on patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic analysis, and the health status of a population. As new knowledge is transformed through the five stages, the final outcome is evidence-based quality improvement of health care.

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Steps in conducting a systematic review

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Formulate question Locate relevant studies Select and appraise studies Summarize and synthesize results Interpret findings Update regularly

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Laws

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Established to protect society Nursing practice guided by legal principles Purpose of laws: -Protect clients/society -Define scope of nursing practice -Identify minimum level of care to be provided

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Health care law

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The collection of laws that have a direct impact on the delivery of health care or on the relationships among those in the business of health care or between the providers and the recipients of health care.

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Legislation

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The process of introducing, adopting, changing, or repealing law.

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Regulation

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The process of putting laws into action through the establishment of rules.

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Litigation

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The process of seeking help through the courts to address a perceived wrong.

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Five traditional legal disciplines:

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Tort law Contract law Property law Constitutional law Criminal law **All legal disciplines have shaped health care law to some degree, but most health care laws are derived from constitutional law and tort law.

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Criminal law

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Federal or state government prosecutes Offense against society Can lead to a fine, imprisonment, or death -Misdemeanor **Minor crime; DUI -Felony **Homicide

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Civil law

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Allows for resolution of dispute between private parties May result in monetary compensation Plaintiff: person bringing suit Defendant: person being sued

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Types of civil law

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Contract law -Dealing with agreements between individuals Explicit or implicit Tort law -Dealing with duties and rights among individuals Involves claims for damages

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State board of nursing

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A state board of nursing holds the legal authority for nursing practice and regulates nursing practice through: Establishing the requirements to obtain a nursing license Issuing nursing licenses Determining the scope of practice Setting minimum education standards Managing disciplinary procedures

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Professional nursing practice

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Is regulated by the states; nurses must hold a state-issued license to practice nursing. Details of the practice of nursing are found in the scope of practice for each state. Practice can vary from state to state; for this reason, nurses should be familiar with the nursing practice act and scope of practice in the state in which they work.

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Quasi-Intentional Torts: Slander

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Oral defamatory statements

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Quasi-Intentional Torts: Defamation

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False communication to a third person

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Quasi-Intentional Torts: Libel

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Written defamatory statements

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Intentional Torts: Assault and battery

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Performing a procedure without consent.

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Intentional Torts: False imprisonment

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Restraining a client against her/his will

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Intentional Torts: Fraud

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Failing to provide essential information for informed consent

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Intentional Torts: Invasion of privacy

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Breach of confidentiality (HIPAA)

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Negligence

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Failure to perform as a reasonable, prudent person would Failure to follow standards of practice No intent to harm is present

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Malpractice

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Tort law or law of medical liability is the legal discipline for malpractice. Four elements must be satisfied: duty, breach, causation, and harm. Is a failure to "follow the standard of care" and is the direct cause of harm. The profession establishes the standard, making this a unique characteristic of medical malpractice.

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Common malpractice claims

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Failure to assess and diagnose Failure to plan Failure to implement a plan of care Failure to evaluate

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Minimizing malpractice risk

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Observe mandatory standards of care Use nursing process; follow professional standards Avoid medication and treatment errors Report and document accurately Obtain informed consent Attend to client safety Maintain client confidentiality Provide education and counseling Delegate, assign, and supervise properly Accept appropriate assignments Participate in continuing education Observe professional boundaries Observe mandatory reporting regulations Be aware of legal safeguards for nurses

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Employer/employee liability

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Vicarious liability Employer liable for the acts of its employee if the employee was acting as an agent of the employer and the actions resulted in injury within that scope of employment.

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Federal laws

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Bill of Rights Social Security Act of 1965 Consolidated Omnibus Budget Reconciliation Act Emergency Medical Treatment and Active Labor Act of 1986 American with Disabilities Act Patient Self-Determination Act of 1991 Health Insurance Portability and Accountability Act of 1996 Patient Protection and Affordable Care Act of 2010

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State laws

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Licensing of professionals—scope of practice -Credentialing -Discipline Licensing of health care institutions Laws relating to public health and disease prevention and control (mandatory reporting laws) -Communicable disease -Abuse Consent Advanced directives Physician-assisted suicide

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HIPAA

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The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress in 1996 to protect patients: ■ Protect health insurance benefits for workers who lose or change their jobs. ■ Protect coverage to persons with preexisting medical conditions. ■ Establish standards to protect the privacy of personal health information.

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Mandatory reporting laws

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The law in various states requires healthcare workers to report communicable diseases. You also have a duty to report physical, sexual, or emotional abuse or neglect of children, older adults, or the mentally ill, whether you suspect it or have actual evidence of it.

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Advanced directives

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Two common forms of advance directives are a living will or health care proxy (POA) -Living will outlines medical treatment client wishes to refuse (ex: intubation) if client unable to communicate wishes at that time -Health care proxy (also called durable power of attorney for health care) appoints someone (usually family or trusted friend) to make health care decisions if client unable to do so

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Safe and effective care environment - Surgery

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Differentiate among the various types and purposes of surgery. Examine individual patient factors for potential threats to safety, especially for older adults. Use appropriate patient identifiers when providing instruction, administering drugs, marking surgical sites, and performing any procedure. Verify that the patient has given informed consent for the surgical procedure and that the presurgical checklist is complete and accurate. Identify patient conditions or issues that need to be communicated to other members of the surgical and postoperative teams.

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Psychosocial integrity - Surgery

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Use effective communication when teaching patients and family members about what to expect during the surgical experience. Act as a patient advocate with regard to patients' rights, informed consent, and advance directives. Identify learning needs for the patient preparing for surgery.

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Physiological integrity - Surgery

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Use knowledge of physiology and behavioral principles to describe an accurate and complete preoperative assessment. Evaluate personal factors that increase the patient's risk for complications during and immediately after surgery. Evaluate laboratory values for changes that may affect the patient's response to drugs, anesthesia, and surgery. Explain the purposes and techniques commonly used for patient preoperative preparation. Apply anti-embolic stockings, sequential compression boots, or other devices to reduce or prevent vascular complications.

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Teamwork and collaboration

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Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

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Pre-operative period

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Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite Nurse functions as educator, advocate, promoter of health and safety

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Surgical settings

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Inpatient -Same day admission Outpatient -Same day surgery Ambulatory -Free standing centers -Physician offices -Ambulatory care centers

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Pre-op assessment includes:

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Current medications - complementary or alternative -herbs -OTC meds Medical history & Family history -Cardiovascular -Pulmonary Previous surgical procedures and anesthesia -Pain control -Management of nausea / vomiting Blood donation Discharge planning - support system

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Older adults: Changes of aging as surgical risk factors

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Decreased: -Cardiac output, peripheral circulation -Vital capacity, blood oxygenation -Blood flow to kidneys, glomerular filtration rate Increased: -Blood pressure -Risk for skin damage, infection -Sensory deficits -Deformities related to osteoporosis/arthritis

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Pre-op system assessment - Cardiovascular

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Affect the ability of the heart to work as an efficient pump. Coronary Artery Disease MI within 6 months before surgery Angina Hypertension Dysrhythmias

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Pre-op system assessment - Respiratory

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Decrease pulmonary function, increase the risk of respiratory infection, and may be exacerbated by general anesthesia. Chronic respiratory problems -Emphysema -Asthma -Bronchitis Smoking -Increases carboxyhemoglobin blood level and deceases oxygen delivery

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Pre-op system assessment - Renal/urinary

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Renal disease/impairment affects the patient's ability to excrete many medications, including anesthetic agents. It also affects the body's ability to regulate fluid and electrolytes.

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Pre-op system assessment - Neurological

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-Determine baseline LOC -Note presence of sensory or perceptual deficits -Assess range of motion and ability to perform activities of daily living

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Pre-op system assessment - Nutrition status

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Patients who are malnourished or obese are at risk for delayed wound healing, infection, and fatigue. Obese clients are also more prone to cardiovascular disorders and impaired pulmonary function.

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Prevention of cardiovascular complications

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-Be aware of patients at greater risk for DVT -Antiembolism stockings -Pneumatic compression devices -Leg exercises -Mobility

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Pre-op Labs

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Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT) Electrolyte levels Serum creatinine level Pregnancy test

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Pre-op Diagnostics

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Chest x-ray - Assesses respiratory status and heart size ECG - Assesses preexisting cardiac disease or rhythm abnormalities

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Nursing Diagnoses - Surgery

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Knowledge deficit (surgical experience) related to unfamiliarity with surgical procedures and preparation. Anxiety related to new or unknown experiences, possibility pain, and possible surgical outcomes.

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Knowledge deficit: Goals & outcomes

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The patient will: Verbalize -in own words purpose and expected results of surgery -understanding of preoperative preparations Ask -questions when terms or procedure is not known Adhere -to NPO requirements Demonstrate -correct use of exercises and techniques to be used after surgery to prevent complications

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Knowledge deficit: Interventions

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*Preoperative teaching *Informed consent: -Surgeon obtains signed consent before sedation and/or surgery -Nurse clarifies facts and dispels myths about surgery -Nurse not responsible for providing detailed information about procedure!

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Informed consent

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Patients may sign with "X" In emergency, telephone authorization is acceptable Special permits required for some procedures

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NPSG's and informed consent

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Ensure correct site is selected and wrong site is avoided Licensed independent practitioner marks site, involving patient if possible "Time out" procedure adopted by most facilities

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Self-determination

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Pt has the right to have or initiate: -Advance directives -Living wills -Durable power of attorney Mandated by the Patient Self-Determination Act Provide legal instructions to healthcare providers ***Surgery does not provide an exception to the patient's advance directives or living will.

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Implementing dietary restrictions

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NPO - Patient not to ingest anything by mouth for 6 to 8 hours before surgery: -Decreases risk for aspiration -Give patients written/oral directions to stress adherence -Surgery can be canceled if instructions not followed

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Administering regularly scheduled medications

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Consult with physician and anesthesia provider for instructions Drugs for certain conditions often allowed with a sip of water: -Cardiac disease -Respiratory disease -Seizures -Hypertension

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Medications that may affect surgery, therefore are a risk

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-Antibiotics - may potentiate the action of anesthetic agents -Anticoagulants - increase risk for bleeding -Antidysrhythmics - may impair cardiac function during anesthesia -Antihypertensives - increase the risk for hypotension during surgery; may interact with anesthetic agents to cause bradycardia and impaired circulation -Aspirin - increase risk for bleeding -Corticosteroids - delay wound healing and increase risk for infection -Diuretics - alter fluid and electrolyte balance (especially potassium balance) -Opiods - increase the risk of respiratory depression -NSAID's - inhibit platelet aggregation, increasing the risk for bleeding -Tranquilizers - increase the risk of respiratory depression

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Intestinal preparation

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Performed to prevent injury to colon; reduce number of intestinal bacteria -Enema or laxative

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Skin preparation

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Skin is first line of defense - break in barrier can lead to infection 1st step in reducing surgical site infection -Can start 1-2 days before surgery with -Antiseptic solutions with shower Removal of hair -DO NOT SHAVE! Clip instead

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Patient and family teaching

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Tubes -Urinary catheter -NG Drains -Penrose -JP -Hemovac Vascular access -PIV -Central Line

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Prevention of respiratory complications

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Breathing exercises -Deep (diaphragmatic) -Expansion Incentive spirometry Coughing and splinting

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Patients at risk for VTE

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Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury Smoking History of VTE, PE, varicose veins, edema Oral contraceptives History of decreased cardiac output Hip fracture, total hip/knee surgery

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Pre-operative chart review

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-Ensure all documentation, preoperative procedures, orders are complete -Check surgical consent form and others for completeness -Inform patient that area will be marked before procedure begins -Document allergies, height, and weight -Ensure all laboratory and diagnostic test results are in chart -Document/report any abnormal results -Report special needs and concerns

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Pre-operative patient preparation

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Remove most clothing; provide gown Leave valuables with family member or lock up Tape rings in place if cannot be removed Ensure patient is wearing ID band Remove: -Dentures -Prosthetic devices -Hearing aids -Contact lenses -Fingernail polish -Artificial nails -Pierced jewelry

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Pre-operative Medications

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Sedatives/Antihistamines - provide sedation and antiemetic effects -hydroxyzine (Vistaril) -diphenhydramine (Benadryl) Hypnotics - provide sedation and increase the duration of sleep -lorazepam (Ativan) -temazapam (Restoril) Anxiolytics - control anxiety, calming -midazolam (Versed) -diazepam (Valium) Opioid analgesics - provide pain relief and sedation; induce anesthesia -morphine (Duramorph) -fentanyl (Sublimaze) Anticholinergic agents - reduce oral and pulmonary secretions, prevent laryngospasms, prevent bradycardia -atropine (Atropisol) -scopolamine (Maldemar) H2 histamine blockers - reduce gastric acidity and reflux -ranitidine (Zantac) -cimetidine (Tagamet)

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Members of the surgical team

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Sterile team: -Surgeon and surgical assistant or RNFA -Scrub nurse -Surgical technologist Clean team: -Anesthesia providers -Circulating nurse -ORTs/surgical technologists may be used in addition to nursing staff -Holding area nurse -Specialty nurses

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Scrub nurse

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Sets up the sterile field Prepares the surgical instruments Assists with the sterile draping of the patient Anticipates and responds to the surgeon's needs Maintains the integrity of the sterile field

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Registered nurse first assistant (RNFA)

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An RN with additional education and training in surgical technique. The RNFA serves as an assistant to the surgeon to perform the surgical procedure, a role that has historically been filled by physicians.

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Anesthesiologist or a nurse anesthetist (CRNA)

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Induces amnesia, analgesia, and muscle relaxation or paralysis with anesthesia. Their role is to continuously monitor and evaluate the patient's responses to the anesthetic agent and the surgical procedure. CRNAs administer more than half of all anesthetics in the United States.

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Circulating nurse

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An RN who applies the nursing process to coordinate all activities in the operating room. She is a client advocate who continuously monitors the client and the sterile field maintains a safe, comfortable environment; communicates with appropriate personnel outside the operating room; responds to emergencies; and, in some cases, administers sedation to the patient. An important aspect of the circulating nurse's role is to attend to the patient during the induction of anesthesia.

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Time out

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The circulating nurse, in the role of patient advocate, is usually the team member who initiates the time out. A correctly performed time out includes verifying the correct: -patient -procedure -site -side (laterality) -surgeon -position As well as that proper equipment, instrumentation, and implants are available.

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What to do if a doctor becomes hypoglycemic during a procedure?

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Nurse has the duty to report impaired practice.

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Minimally invasive and robotic surgery (MIS)

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Now common practice Preferred technique for many surgery types, including: Cholecystectomy Joint surgery Cardiac surgery Splenectomy Spinal surgery Potential injury Mechanical trauma Thermal injury

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Environment of the surgical team

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Preparation of surgical suite, team safety Layout Health and hygiene of surgical team Surgical attire Surgical scrub Remember!!! People are a source of bacteria in the surgical setting! Special health care standards, dress are needed Watch for nosocomial infections, identify source of pathogens

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Surgical scrubbing

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Broad-spectrum, surgical antimicrobial solution Vigorous rubbing that creates friction used from fingertips to elbow Scrub continues for 3 to 5 min

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Anesthesia

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Induced state of partial or total loss of sensation, occurring with or without loss of consciousness Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, achieve controlled level of unconsciousness (in some cases)

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General anesthesia

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Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS Involves single or combination of agents Depresses CNS, resulting in analgesia, amnesia, and unconsciousness with loss of muscle tone and reflexes

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Stages of general anesthesia

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Stage 1—Beginning of anesthesia; client is drowsy and dizzy; pain sensation is depressed Stage 2—Excitement stage; client has irregular breathing, involuntary motor movements; avoid stimulating client, which can trigger vomiting, holding the breath, and increased activity; ensure client safety by proper use of safety straps Stage 3—Stage of anesthesia appropriate for surgical procedures; client has skeletal muscle relaxation, constricted pupils, absence of eyelid reflex Stage 4—medullary depression; client is NEAR DEATH; pupils are fixed and dilated, respirations are weak, pulse is rapid and thready Emergence—recovery from anesthesia

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Administration of general anesthesia

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Inhalation IV injection Balanced anesthesia Adjuncts to general anesthetic agents: -Hypnotics -Opioid analgesics -Neuromuscular blocking agents

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Balanced anesthesia

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Combination of IV drugs and inhalation agents used to obtain specific effects Example: -thiopental for induction -nitrous oxide for amnesia -morphine for analgesia -pancuronium for muscle relaxation

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Complications of general anesthesia

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Malignant hyperthermia Overdose Unrecognized hypoventilation Problems with specific anesthetic agents Intubation problems

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Malignant hyperthermia

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Acute, life-threatening complication May be genetic Begins with skeletal muscle exposed to specific agent Causes increased metabolism, calcium levels in muscle cells Leads to acidosis, high temperatures, dysrhythmias

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Clinical presentations of malignant hyperthermia

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-Tachycardia -Tachypnea -Skin initially appears flushed, then becomes mottled and cyanotic -Myoglobinuria -Rise in end tidal carbon dioxide -Rapid rise in body temperature -Respiratory and metabolic acidosis

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Regional anesthesia

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Blocks multiple peripheral nerves in specific body region: Field Nerve Spinal Epidural

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Regional - Local anesthetic

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Briefly disrupts sensory nerve impulse transmission from specific body area/region Delivered topically and by local infiltration Patient remains conscious, able to follow instructions Injected in a specific area for minor surgical procedures, such as lidocaine for suturing a small wound

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Regional - Field block

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Injection of anesthetic around the operative field.

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Regional - Nerve block

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Anesthetic agent is injected into and around a nerve or group of nerves, such as a pudendal block used to numb perineum for an episiotomy.

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Regional - Spinal block

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Anesthesia is injected through a lumbar puncture into subarachnoid space, such as for hernia repairs or cesarean section deliveries Patient is conscious but has no sensation or movement of lower extremities up to a specific area.

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Regional - Epidural block

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Anesthetic agent injected into epidural space to anesthetize larger areas, such as in vaginal childbirth; Patient is awake and aware of surroundings but feels no pain

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Complications of regional and local anesthesia

answer

Anaphylaxis Incorrect delivery technique Systemic absorption Overdose Local complications

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Treatment of complications of anesthesia

answer

Establish open airway Give oxygen Notify surgeon Fast-acting barbiturate is usual treatment Epinephrine for unexplained bradycardia

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Moderate sedation

answer

IV delivery of sedative, hypnotic, opioid drugs to reduce level of consciousness Patient maintains patent airway, can respond to verbal commands Amnesia action is short

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Potential for injury

answer

Interventions: Proper body position Prevent pressure ulcer formation Prevent obstruction of circulation, respiration, nerve conduction

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Potential for infection

answer

Interventions include: Plastic adhesive drape Skin closures, sutures and staples, nonabsorbable sutures Insertion of drains Application of dressing Patient transfer from OR table to stretcher

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Potential for hypoventilation

answer

Continuous monitoring of: -Breathing -Circulation -Cardiac rhythms -Blood pressure and heart rate Continuous presence of anesthesia provider

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Potential for hypoxemia

answer

Highest incidence occurs on 2nd postoperative day Interventions: -Airway maintenance -Monitor (Spo2) -Semi-Fowler's position -Oxygen therapy, breathing exercises -Mobilization as soon as possible

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Potential for wound infection and delayed healing

answer

Interventions: Nursing assessment of surgical area Dressings—first change usually done by surgeon Drains—provide exit route for air, blood, bile; help prevent deep infections, abscess formation during healing Drug therapy, irrigation to treat wound infection Débridement Surgical management required for wound opening

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Post-operative period

answer

Begins with completion of surgery and transfer to PACU, ambulatory care unit, or ICU

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PACU recovery room

answer

During this period, the client is at high risk for respiratory and cardiovascular compromise. As a precaution, the anesthetist and the circulating nurse accompany the client and attend to his needs during transport to the PACU. Ongoing evaluation and stabilization of patients to anticipate, prevent, manage complications after surgery The Joint Commission's NPSGs require circulating nurses and anesthesia providers give PACU nurses verbal hand-off reports including surgical procedure, anesthesia, drugs and IV fluids administered, and estimated blood loss

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Functions of the PACU nurse

answer

Respiratory LOC, TPR, O2 Sat, BP Examine surgical area Discharge from PACU

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What to do if patient is confused in the PACU

answer

Orient the patient. Let them know where they are, how they got there, the time, day, etc.

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Post-op: Respiratory system assessment

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-Patent airway, adequate gas exchange -Note artificial airway when applicable -Rate, pattern, depth of breathing -Breath sounds -Accessory muscle use -Snoring and stridor -Respiratory depression or hypoxemia

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Post-op: Cardiovascular assessment

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Vital signs every 15 mins until stable Heart sounds Cardiac monitoring Peripheral vascular assessment -Monitor for VTE

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Post-op: Neurological assessment

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Cerebral functioning Motor and sensory assessment after epidural or spinal anesthesia

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Post-op: Fluid, electrolyte & acid-base balance assessment

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I & O Hydration status IV fluids Vomitus Urine Wound drainage NG tube drainage Acid-base balance

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Post-op: Renal/urinary system assessment

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Check for urine retention Consider other sources of output (e.g., sweat, vomitus, diarrhea stools) Report urine output of < 30 mL/hr

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Post-op: Gastrointestinal assessment

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Postoperative nausea/vomiting common 30% of patients experience nausea or vomiting after general anesthesia Peristalsis may be delayed up to 24 hours Monitor for bowel sounds **Absent bowel sounds common due to meds that decrease peristalsis, not a big concern immediately after surgery

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Post-op: Drug therapy to reduce nausea/vomiting

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Ondansetron (Zofran) Meclizine (Antivert, Dramamine)

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Post-op: NG tube drainage

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Inserted during surgery to: Decompress and drain stomach Promote GI rest Allow lower GI tract to heal Provide enteral feeding route Monitor any gastric bleeding Prevent intestinal obstruction **Assess drained material every 8 hr

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Post-op: Skin/incision assessment

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Normal wound healing **draining wound does not mean infected wound** Impaired wound healing - seen most often between 5th and 10th days after surgery -Dehiscence -Evisceration Marking post op drainage: How: Any drainage is on the dressing, the nurse circles the area and marks it with a time and date. Provides a gauge how much seepage is occurring. When to notify surgeon: When excessive bleeding or hematoma formation has occurred, the surgeon should be notified right away so that the wound site assessment can be performed.

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Post-op: Management of nicotine withdrawal

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Transdermal nicotine patch

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Gravity drains

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Gravity drains: -Penrose: Short-term drain to give fluids under the wound a channel to drain to the surface; prevents pressure on suture lines -T-tube: Drain directly through a tube from the surgical area

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Closed-wound drainage systems

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Jackson-Pratt Hemovac: drainage collects in a collecting vessel by means of compression and re-expansion of the system.

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Montgomery straps

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Used when frequent dressing changes are anticipated. They help prevent skin irritation from frequent tape removal.

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Application of skin staples

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The stapler is lightly positioned over everted skin edges. It is not necessary to press the staple, or stapler anvil, into the skin to get a proper "bite" (just "kiss" the skin). Center the staples over the incision line, using the locating arrow or guideline, and place staples approximately ¼ inch apart.

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Post-op: Discomfort/pain assessment

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Pain/discomfort is expected after surgery Physical and emotional signs of pain Consider type, extent, length of surgical procedure in assessing patient's discomfort, need for medication

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Physical and emotional signs of acute pain

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Increased pulse and blood pressure Increased respiratory rate Profuse sweating Restlessness Confusion (older adults) Wincing, moaning, crying

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Pain interventions

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Drug therapy Complementary & alternative therapies: -Positioning -Massage -Relaxation/diversion techniques

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Post-op: Laboratory assessment

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Analysis of electrolytes CBC "Left-shift" (bandemia) Specimens for C&S ABGs Urine and renal laboratory tests Other (e.g., serum amylase, blood glucose)

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Incentive spirometry

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Encourage incentive spirometer, deep breathing and coughing exercises every 2 hours while awake to prevent atelectasis and pneumonia.

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Post-surgical patient education: Diet

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Drink at least 6 to 8 glasses of fluid daily unless otherwise ordered (water is beneficial) Adhere to any diet restrictions (provide individualized instruction according to diet) Eat well-balanced meals that are high in vitamin C and protein to aid wound healing

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Post-surgical patient education: Activity

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Maintain activity restriction if ordered by surgeon Resume activities gradually (all clients) Avoid heavy lifting for 6 weeks after major surgery Avoid lifting more than 10 pounds or performing activities involving pushing or pulling with an abdominal incision Often may return to work in 6 to 8 weeks (depending on surgery and client status preoperatively)

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Post-surgical patient education: Wound care

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Take care of incision and/or change dressing as taught (specific information is individualized to client and surgery; provide 1 to 2 days of dressing materials or according to hospital policy) Cover incision with plastic wrap before showering (if allowed) Sutures or staples are often removed in surgeon's office 7 to 14 days post operatively Steri-Strips will fall off by themselves (if used instead of sutures or if applied for support when sutures are removed before discharge) Keep wound clean, dry, and intact

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