Bowel
Describe bowel sounds
Hyperactive: Loud, High Pitch, Rushing
Hypoactive: Sluggish
Absent: Must listen for 5 mins ( s/s of ileus or bowel obstruction)
Types of Urinary Elimination Terms
-Enuresis (involuntary urination – children at night)
-Urgency (urgent need to urinate despite bladder not being full)
-Incontinence (leaks urine accidentally)
-Frequency (the need to urinate more than normal)
S/S of Hypothermia
Decrease Temp, BP, & Respirations
Skin is Pale & Cool
Decrease muscle coordination & Urinary Output
What does Afebrile Mean
Without Fever
How to correct HYPERNATERMIA
Administer Hypotonic Solution
If a pt is on an opioid, what needs to be prescribed and explain medications
Stool Softeners/ Laxatives
Laxatives: Stimulates bowel movement
Cathartics: Stong Laxative- Changes in GI transit time
Enemas: Stimulates BM
Stool Softners: Brings H2O into the stool to help soften it.
S/S of Urinary Incontinence
•Frequent urination
•Feeling uncontrollable urges to urinate
•Leaking urine, especially when coughing, sneezing
•Waking up many times to urinate or urinating during sleep
Explain Heat EXHAUSTION
Prolong/extreme heat exposure that leads to profuse sweating.
This leads to a loss of electrolytes & fluid volume deficit
What amt of output needs to be reported to MD?
You write this down on your clinical paperwork
30 ml/hr
Nursing Interventions for HYPERKALEMIA
**NEVER IV PUSH K+
-Monitor the following:
VS (Especially HR and Rhythm)
I&O
Cardiac Rhythm with ECG
Lab Values
Limit high K+ food!!
Administer Kayexalate as ordered.
Administer glucose and insulin as ordered.
Diet for Optimum Bowel, Diarrhea, Constipation, Tube Feeding
Optimum Bowel: Increase fiber and H20 intake
Dirrahea: Bland small meals, room temp liquids, avoid dairy, gasy, spicy foods
Constipation: Increase fiber and H20 intake
Tube Feeding: Safe food handling and add bulking agent. May have dirrahea
Types of Urinary Cath
Foley – allow urine to drain if structures are not operating correctly such as bladder weakness or nerve damage, Surgery – epidurals. Last treatment for incontinence.
Condom – usually used by men for urinary incontinence
Suprapubic – urethra damaged or blocked or an ill candidate for intermittent catheters. Usually changed every 4-6 weeks. Urologist or nurse specialist with special skills establishes initial cath then can be changed by certified RN
Explain a heat STROKE & s/s
Prolonged heat exposure
S/S- Confusion, Delirium, Excessive thirst, Nausea, Muscle Cramps, Increase Body Temp and HR
*** HOT AND DRY SKIN
S/S of Urinary Tract Infection
-Urge to urinate frequently
-Burning during urination
-Cloudy and/or bloody urine
-Pressure/cramping lower abdomen
Neuro Muscular S/S of Hypocalcemia
+ Trousseau and Chvostek signs
Hyperactive deep tendon reflexes
Irritable skeletal muscles: Twitches, cramps, tetany, seizures
Painful muscle spasms in the calf or foot during periods of inactivity.
Explain bowel patterns
Diarrhea: Abnormal, frequent, liquid BM's ( Hersey Squirts)
Incontinence: Loss of voluntary control over bowel
Constipation: Infrequent or difficult BM's or LESS THAN 3 BM'S IN 1 WEEK.
TYpes of Urinary Diversions
Ureterostomy - the urine bypasses the bladder and exits the body through a stoma—a surgically created opening—and collects into a pouch worn outside the body.
Vesicostomy - an opening created by the doctor between the abdominal wall and the bladder.
Ileal conduit – Removal of bladder - After the operation, your urine will run down the ureters, through the piece of ileum and out through the stoma. ureters are detached from the bladder and joined to a short length of the small intestine (ileum)
Common sites for hypothermia
Tips of finers, ears, toes.
***GRADUAL WARMING***
Lab Values for Kidney Function
-BUN-10-20
-CRT- 0.3-1.3
Clinical Manifestations of Hypovolemia
There are several ones but think about 1 major one that will lead to others...
Decreased circulating blood volume and inadequate tissue perfusion
Describe Colostomies
Sigmoid: @ end of descending or sigmoid colon in LLQ.
Transverse: @ transverse colon- Middle/Right Side
Ascending: @ ascending colon. More Runny Stools. Can't be regulated
Descending/Sigmoid- More formed stool- Can be "regulated"
6 Types of Urinary Incontinence
•Stress- Unintentionally urinating during activity such as sneezing, coughing etc
•Urge- Sudden urge to void followed by rapid voiding
•Mixed- Stress + Urge
•Functional- Lack of control re: urination due to physical limitations outside the urinary pathway is impacted
•Overflow- Constant leaking of urine due to inability to empty bladder completely
•Temporary- Typically associated with secondary condition such as infections or medication
Anorexia, Headaches, Malasie, Hot/Dry Skin, Flush, Shivering
Foods high in K+
Avocado Bananas Cantaloupe Carrots Fish Mushrooms
Oranges Pork Beef Veal Potatoes Raisins Spinach
Strawberries Tomatoes
Questions and Things to pay attention too when speaking to pt's regarding food.
-Always ask about religious or cultural beliefs. This will determine what foods they may or may not have.
-Assess pt’s ability to swallow and if they can chew up the food
-Teach pt’s to rinse off can veggies due to high NA levels.
-Ask pt’s about food allergies and any medications they are currently taking.
- Ask if they are able to afford food (fresh fruit)