NSG124
clean catch specimen - ANS Use sterile container and only touch outsideof container. Women:
separate labia with one hand and clean meatus with other hand, using at least three sponges
(saturated with cleansing solution) in front to back motion. Men: retract foreskin (if present)
cleanse glans with atleast three cleansing sponges. Replace foreskin. After cleaning, instruct
patient to begin urinating & then continue to void into container. Initial voided urine flushes out
contaminants in urethra/perineal area. Catheterization may be needed if patient is unable to
cooperate with procedure.
How is fluid loss/gain most accurately evaluated? - ANS Daily weights
3-way Foley or triple lumen catheter - ANS Bladder irrigation typically done to remove clotted
blood from the bladder and ensure drainage of urine. Can be done manually on an intermittent
basis or more commonly as continuous bladder irrigation. (CBI).
Calcium (Ca) - ANS 8.2-10.2 mg/dL
Potassium (K) - ANS 3.5-5.5 mEq/L
Magnesium (Mg) - ANS 1.5-2.5 mEq/L
Sodium (Na) - ANS 136-145 mEq/L
3way Foley stuff - ANS Blood clots expected first 24-36 hours, but bright red blood is not.
Displacement of catheter, dislodgment of lg clot, or abdominal pressure are abnormal findings.
Sitting and walking for prolonged periods should be avoided, also avoid straining/Valsalva
Maneuver.
Oxybutynin - ANS Ditropan. Antispasmodic. Indicated for Urinary symptoms that may be
associated with neurogenic bladder including:
Frequent urination,
Urgency,
Nocturia,
Urge incontinence.
Assessment of Urinary System - ANS Past Health History: Hypertension, Diabetes, gout and
other metabolic problems, connective tissue disorders (ex. Lupus), skin, upper respiratory
infections, viral hepatitis, congenital disorders, neurological disorders or trauma. Note all
medications, some can be "Nephrotoxic".
Subjective: painful urination? Changes in color of urine? Changes in characteristics of urination
(diminished, excessive)? Nocturnal?
,Diagnostic: BUN/Creatinine. Urinalysis. Urine Culture and Sensitivity.
Objective: Inspect Abdomen. Urinary meatus for inflammation or discharge.
Palpate: abdomen for bladder distention, masses, or tenderness.
Percuss: costovertebral angle for tenderness.
Female Urethra 1-2 inches long
Male 8-10 inches long
Kidneys sit from T12 to L3. Right kidney at 12th rib, slightly lower.
Normal post void residual - ANS 50-75mL
Urinary Retention Interventions - ANS Double voiding: urinate, sit on toilet 3-4 minutes, and then
urinate again before exiting the bathroom. Intermittent Catheterization, or perhaps indwelling if
obstruction is the cause of retention. Drug Therapy. Scheduled toileting..
Nursing Management of Urinary Calculi - ANS Nursing assessment. Recent or chronic UTI?
Medications? Surgery? Pain? Fever? Labs?
Impaired urinary elimination related to trauma or obstruction of ureters or urethra. Acute pain
related to effects of stones and in adequate pain control or comfort measures.
Goals, relief of pain. No urinary tract obstruction and knowledge of ways to prevent recurrence
of stone.
Drink at least 2 L per day. Moderate activity. Fluid intake must be higher in active person.
Preventative measures for bedridden person.
Strain all urine. Assist with ambulation to the bathroom with pain meds on board.
Prevention of UTI - ANS Take all antibiotics as prescribed to prevent reoccurring infection.
Practice appropriate hygiene, including carefully cleaning the perineal region by separating the
labia when cleansing. Wipe from front to back after urinating. Cleanse with warm soapy water
after each bowel movement. Empty bladder before and after sexual intercourse. Urinate
regularly, every 3-4 hours during the day. Maintain adequate fluid intake. Avoid vaginal douches,
harsh soaps, bubble baths, powders, and sprays in the perineal area. Report to HCP s/s of UTI :
fever, cloudy urine, pain on urination, urgency, frequency. Consider drinking unsweetened
cranberry juice [8oz 3xqday] or taking cranberry extract tabs 300-400 mg/day for UTI prevention
[this practice may not be effective in every patient].
, What is TURP - ANS Transurethral Resection of the Prostate is a surgical procedure involving
the removal of prostate tissue using a resectoscope inserted through the urethra. Purpose is for
surgical treatment of BPH [Benign Prostatic Hyperplasia]... enlarged prostate.
Nutritional Assessment - ANS Anthropometric Measurements : height, weight, BMI, rate of
weight change, amount of weight loss. Physical Exam: Physical Appearance, muscle mass and
strength, dental and oral health. Health History: Personal/Family History, acute/chronic illness,
current meds, herbs, supplements, cognitive status and depression. Diet History:
Chewing/Swallowing ability. Changes in appetite/taste. Food/nutrient intake. Availability of food.
Laboratory Data: glucose, electrolytes, lipid profile, BUN, albumin, prealbumin, CRP. Functional
status: ability to perform basic and instrumental activities of daily living, handgrip strength, and
performance tests-- timed walk tests.
Gastrointestinal System Assessment - ANS Mouth: Moist/pink lips. Pink and moist buccal
mucosa & gingivae without plaques or lesions. Teeth in good repair. Protrusion of tongue in
midline without deviation or fasciculations. Swallows smoothly.
Abdomen: flat without masses or scars, no bruises. Positive bowel sounds in all four quadrants.
No tenderness, nonpalpable liver and spleen. Liver 10cm right midclavicular line. Generalized
TYMPANY.
Anus: absence of lesions, fissures, hemorrhoids. Good sphincter tone. Rectal walls smooth/soft.
No masses. Stool soft, brown, heme negative.
Nursing Actions for Malnutrition - ANS Collaboration with HCP/dietitian. Assess patients
nutritional state. Increased stress, surgery, severe trauma, and sepsis may require more
calories and protein.
Measure height/weight on admission, routine reassess. Body weight provides clearer picture of
patients fluid and nutritional State. PO food = calorie count. Conducive environment for eating.
In between meal supplements. May need appetite stimulants such as megestrol acetate or
dronabinol. Enteral or Parental feedings may be considered.
gastrectomy postoperative - ANS NG tube but will not drain a large quantity. Watch for fluid
leakage at the anastomosis site as evidenced by elevated temperature & increased dyspnea.
There can be impaired healing due to poor nutrition, IV/Oral replacement of vitamins C,D,K,B
and cobalamin. Anemia is a possibility.
Gastric Surgery post op - ANS Bowel sounds generally absent early post op period. NG low
intermittent suction or low continuous. Analgesics. Cough;deep breath. Semifowlers. Dry
dressing. Frequent mouth care. I/O.
Postprandial hypoglycemia - dumping syndrome - ANS Occurs postop (gastrectomy) when
food/fluid pass quickly in jejunum which produces fluid shift from blood stream to jejunum. S/S
clean catch specimen - ANS Use sterile container and only touch outsideof container. Women:
separate labia with one hand and clean meatus with other hand, using at least three sponges
(saturated with cleansing solution) in front to back motion. Men: retract foreskin (if present)
cleanse glans with atleast three cleansing sponges. Replace foreskin. After cleaning, instruct
patient to begin urinating & then continue to void into container. Initial voided urine flushes out
contaminants in urethra/perineal area. Catheterization may be needed if patient is unable to
cooperate with procedure.
How is fluid loss/gain most accurately evaluated? - ANS Daily weights
3-way Foley or triple lumen catheter - ANS Bladder irrigation typically done to remove clotted
blood from the bladder and ensure drainage of urine. Can be done manually on an intermittent
basis or more commonly as continuous bladder irrigation. (CBI).
Calcium (Ca) - ANS 8.2-10.2 mg/dL
Potassium (K) - ANS 3.5-5.5 mEq/L
Magnesium (Mg) - ANS 1.5-2.5 mEq/L
Sodium (Na) - ANS 136-145 mEq/L
3way Foley stuff - ANS Blood clots expected first 24-36 hours, but bright red blood is not.
Displacement of catheter, dislodgment of lg clot, or abdominal pressure are abnormal findings.
Sitting and walking for prolonged periods should be avoided, also avoid straining/Valsalva
Maneuver.
Oxybutynin - ANS Ditropan. Antispasmodic. Indicated for Urinary symptoms that may be
associated with neurogenic bladder including:
Frequent urination,
Urgency,
Nocturia,
Urge incontinence.
Assessment of Urinary System - ANS Past Health History: Hypertension, Diabetes, gout and
other metabolic problems, connective tissue disorders (ex. Lupus), skin, upper respiratory
infections, viral hepatitis, congenital disorders, neurological disorders or trauma. Note all
medications, some can be "Nephrotoxic".
Subjective: painful urination? Changes in color of urine? Changes in characteristics of urination
(diminished, excessive)? Nocturnal?
,Diagnostic: BUN/Creatinine. Urinalysis. Urine Culture and Sensitivity.
Objective: Inspect Abdomen. Urinary meatus for inflammation or discharge.
Palpate: abdomen for bladder distention, masses, or tenderness.
Percuss: costovertebral angle for tenderness.
Female Urethra 1-2 inches long
Male 8-10 inches long
Kidneys sit from T12 to L3. Right kidney at 12th rib, slightly lower.
Normal post void residual - ANS 50-75mL
Urinary Retention Interventions - ANS Double voiding: urinate, sit on toilet 3-4 minutes, and then
urinate again before exiting the bathroom. Intermittent Catheterization, or perhaps indwelling if
obstruction is the cause of retention. Drug Therapy. Scheduled toileting..
Nursing Management of Urinary Calculi - ANS Nursing assessment. Recent or chronic UTI?
Medications? Surgery? Pain? Fever? Labs?
Impaired urinary elimination related to trauma or obstruction of ureters or urethra. Acute pain
related to effects of stones and in adequate pain control or comfort measures.
Goals, relief of pain. No urinary tract obstruction and knowledge of ways to prevent recurrence
of stone.
Drink at least 2 L per day. Moderate activity. Fluid intake must be higher in active person.
Preventative measures for bedridden person.
Strain all urine. Assist with ambulation to the bathroom with pain meds on board.
Prevention of UTI - ANS Take all antibiotics as prescribed to prevent reoccurring infection.
Practice appropriate hygiene, including carefully cleaning the perineal region by separating the
labia when cleansing. Wipe from front to back after urinating. Cleanse with warm soapy water
after each bowel movement. Empty bladder before and after sexual intercourse. Urinate
regularly, every 3-4 hours during the day. Maintain adequate fluid intake. Avoid vaginal douches,
harsh soaps, bubble baths, powders, and sprays in the perineal area. Report to HCP s/s of UTI :
fever, cloudy urine, pain on urination, urgency, frequency. Consider drinking unsweetened
cranberry juice [8oz 3xqday] or taking cranberry extract tabs 300-400 mg/day for UTI prevention
[this practice may not be effective in every patient].
, What is TURP - ANS Transurethral Resection of the Prostate is a surgical procedure involving
the removal of prostate tissue using a resectoscope inserted through the urethra. Purpose is for
surgical treatment of BPH [Benign Prostatic Hyperplasia]... enlarged prostate.
Nutritional Assessment - ANS Anthropometric Measurements : height, weight, BMI, rate of
weight change, amount of weight loss. Physical Exam: Physical Appearance, muscle mass and
strength, dental and oral health. Health History: Personal/Family History, acute/chronic illness,
current meds, herbs, supplements, cognitive status and depression. Diet History:
Chewing/Swallowing ability. Changes in appetite/taste. Food/nutrient intake. Availability of food.
Laboratory Data: glucose, electrolytes, lipid profile, BUN, albumin, prealbumin, CRP. Functional
status: ability to perform basic and instrumental activities of daily living, handgrip strength, and
performance tests-- timed walk tests.
Gastrointestinal System Assessment - ANS Mouth: Moist/pink lips. Pink and moist buccal
mucosa & gingivae without plaques or lesions. Teeth in good repair. Protrusion of tongue in
midline without deviation or fasciculations. Swallows smoothly.
Abdomen: flat without masses or scars, no bruises. Positive bowel sounds in all four quadrants.
No tenderness, nonpalpable liver and spleen. Liver 10cm right midclavicular line. Generalized
TYMPANY.
Anus: absence of lesions, fissures, hemorrhoids. Good sphincter tone. Rectal walls smooth/soft.
No masses. Stool soft, brown, heme negative.
Nursing Actions for Malnutrition - ANS Collaboration with HCP/dietitian. Assess patients
nutritional state. Increased stress, surgery, severe trauma, and sepsis may require more
calories and protein.
Measure height/weight on admission, routine reassess. Body weight provides clearer picture of
patients fluid and nutritional State. PO food = calorie count. Conducive environment for eating.
In between meal supplements. May need appetite stimulants such as megestrol acetate or
dronabinol. Enteral or Parental feedings may be considered.
gastrectomy postoperative - ANS NG tube but will not drain a large quantity. Watch for fluid
leakage at the anastomosis site as evidenced by elevated temperature & increased dyspnea.
There can be impaired healing due to poor nutrition, IV/Oral replacement of vitamins C,D,K,B
and cobalamin. Anemia is a possibility.
Gastric Surgery post op - ANS Bowel sounds generally absent early post op period. NG low
intermittent suction or low continuous. Analgesics. Cough;deep breath. Semifowlers. Dry
dressing. Frequent mouth care. I/O.
Postprandial hypoglycemia - dumping syndrome - ANS Occurs postop (gastrectomy) when
food/fluid pass quickly in jejunum which produces fluid shift from blood stream to jejunum. S/S
