Gut Skills

GUT SKILLS By: liezel a. castillo r.n.,m.d.

Changes in Amount or Color of Urine • Pol yuri a= >60 cc/hour urine output common in DM, DI, and use of drugs • Oliguri a=100-500cc/day urine output common in ARF, shock, dehydration and F&E imb. • Anur ia =<50 cc/day or no urine output due to obstruction or other disease

Changes in Amount or Color of Urine • •

He mat uria Blood in the urine=serious sign and requires evaluation • Dark, rusty urine=bleeding from upper ureters • (GROSS) Bright red bloody urine=bleeding from lower ureters • (MICROSCOPIC) hematuria=bleeding from renal parenchyma • Painless hematuria=may indicate neoplasm in the BLADDER

Changes in Amount or Color of Urine •

• • • •

Pn eu ma turi a=passage of gas in urine during voiding caused by bowel and bladder fistula rectosigmoid cancer, regional ileitis, sigmoid diverticulitis (common) and gas forming UTI Pr otei nu ria=presence of CHON in the urine Ke tonu ria =presence of ketone bodies in the urine Azo tem ia =build up of nitrogenous waste products in the blood Ur emia =presence of urine in the blood

Symptoms Related to Irritation of the Lower Urinary Tract • Dysuria=pain or difficult urination (UTI=burning sensation) • Frequency=voiding occurs more often than usual (normal=once every 3-6 hours) • Urgency=strong desire to urinate that is difficult to control due to inflammation of the bladder, prostate and urethra. • Nocturia =excessive urination at night that interrupts sleep • Strangury =slow and painful urination, only small amount of urine is voided (cystitis)

Symptoms Related to Irritation of the Lower Urinary Tract Pain: • During and after voiding=bladder • Flank=kidneys and ureters • Start of voiding=urethra

Symptoms Related to Obstruction of the Lower Urinary Tract • Weak Stream=decreased force of stream • Hesitancy=undue delay and difficulty in initiating voiding (neurogenic bladder) • Terminal Dribbling=prolonged dribbling of urine from the meatus after urination is complete • Incomplete emptying=feeling that the bladder is still full even after • urination. May lead to infection.

Types of Urinary Incontinence • Incontinence=involuntary loss of urine may be due to pathologic, • anatomical or physiologic factors. • Stress=intermittent leakage of urine due to increased abdominal • pressure (coughing, straining and sneezing) • Urge=sensation of the need to urinate followed by sudden involuntary loss of urine

Types of Urinary Incontinence • Overflow = loss of urine caused by overdistention of the bladder. • Total = continous leakage of urine due to injury of the sphincteric mechanisms, bladder and urethra. • Functional = loss of urine due to functional impairment (inability to go to the bathroom or positioned to void) • Mixed = combination of two or more types of incontinence • Enuresis = involuntary voiding during sleep (obstructive or neurogenic)

Laboratory Procedures

•

Co lle ction of Ur in e Sp ecimen Random Ur ine S ample • Cle an • Ur inal ysis Ex am

• Ur ine S tr aining

• Cle an • To c ol le ct s tone

• 24° Ur ine Collecti

on

• Cle an • To m on ito r ur ine ou tput an d c rea tini ne cl ea ranc e

• Clean Catch U rine

• St er il e • Cul tur e an d Se nsi tivit y Te st

• Mid-strea m Cat ch Ur ine • St er il e • Cul tur e an d Se nsi tivit y Te st C athe teri za tion

Urinalysis • It involves overall characteristics of urine: Appear ance • Normal urine is clear • Cloudy=due to pus, blood, bacteria and lymph fluid Odor • Normal is faint aromatic odor • Offensive odor=bacterial action

Urinalysis Col or • Normal is clear yellow or amber • Straw colored = diluted • Highly colored = concentrated urine due to insufficient fluid intake • Cloudy or smoky = hematuria, spermatozoa • Red or red brown = bleeding or drugs and food • Yellow-brown or green-brown = obstructive jaundice or lesion from bile duct • Dark-brown or black = malignant melanoma or leukemia

Urinalysis pH • Maintain normal hydrogen ion concentration in plasma and ECF • Must be measured in fresh urine because the breakdown of Urine to ammonia causes urine to become alkaline • Normal pH is around 6 (acid) or 4.6-7.5 Spe cif ic g ravity • Reflects ability of the kidneys to concentrate or dilute urine, Normal range is from 1.010-1.025 Osmola lit y • More precise test than specific gravity • 1-2 ml urine are required • Normal range is from 300-1090 mOsm/L (number of particles per unit volume of water)

Urinalysis Prot ein • Prot einur ia 150 mg /24 hr s may ind icat e re na l disea se • 24 ho ur urin e • Can be aff ect ed by prote in i ntak e Ur ine ca st s ( tiny de pos its of sub st an ces on th e wall s of rena l tu bu les) RBC =glome ru lon ep hr itis Fa tt y ca st s=n ep hr ot ic synd ro me WBC=p ye lone phr itis, coll ect ran dom urine sp ecimen Or ga nic wast e (solut e of ur ine)=ur ea , cr ea tinine , ammo ni a and uric ac id Inor ga nic was te (solu te of ur ine)=Na, K, Cl, S O4 an d P

Catheterization • Done to relieve acute or chronic urinary retention • Drain urine pre/postoperatively • Determine the amount of residual urine after voiding • For accurate measurement of urinary drainage in critically ill patient (strict intake and output) • Suprapubic (incision on the abdomen) • Done for acute urinary retention when urethral catheterization is not possible • To obtain an uncontaminated urine sample

Catheterization • Coude (for constricted or stenosed urethra) • Straight cath (intermittent cath) • Indwelling cath/foley cath (strict I&O) • 3 way cath (cystoclysis, 3 way bladder irrigation)

Catheterization Cont inuous bl adder irri gati on • Irrigation, drainage, inflation port (3 ports) • Done after prostate resection • Initial drainage must be • pinkish in color (normal) • bloody (abnormal)

• Avoid clot formation in the drainage • if drainage suddenly stops look for obstruction or kinking of the tube • If there is no drainage in the absence of kinking, suspect blood clot

Urinary Diversion Vesicostomy • The bladder is sutured to the abdominal wall and creates an opening

Urinary Diversion Nephrostomy • Renal pelvis is catheterized and brings it out to the skin

Urinary Diversion • Cutaneous Ureterostomy • Detached ureter is surgically positioned to an opening in the skin

Urinary Diversion Ileal Conduit • Cut section of the ileum is surgically placed in the abdomen • Stoma must be pinkish and moist • Clean stoma with soap and water. Keep it dry. • Avoid urine contact to the skin • Use vinegar for cleaning the bag • Cover the stoma when cleaning with gauze pad

Urinary Diversion Colon Conduit • The ureters are attached to the colon • Increased risk of infection

Creatinine Clearance Test (urine specimen) • Measures the rate of kidneys ability to clear creatinine from the blood • 24 hour urine collection then draw one sample of blood within the period • Most sensitive test for renal disease • GFR assessment • 24 hour urine collection to detect renal disease • Discard first voided urine in the morning and start the collection process • Refrigerate all collected urine immediately to avoid contamination

Test of Renal Function • To check renal excretory functions • There is no single test of renal function, best results are obtained by combining a number of clinical tests • Renal function is variable from time to time • Renal function may be within normal limits until 50% of renal function is lost.

Blood Studies Blo od Ur ea Nitr ogen BU N • primary end product of protein metabolism and is excreted by the kidneys • an elevation of BUN may indicate impaired kidneys • not specific for the kidney function • normal value=20-30 mg/dl

Blood Studies

Ser um Cr eat inin e • specific for renal function test • not affected by dietary intake or hydration status • normal value 0.5-1.5 mg/dl • elevated in cases of glomerulonephritis • Pyelonephritis, acute tubular necrosis, nephrotoxicity, renal insufficiency and renal failure. • not reabsorb by the kidney tubules

Blood Studies • Serum Electrolytes • All electrolytes will elevate except calcium in CRF

• CBC • RBC count is reduced in CRF

Radiology and Imaging • These tests include simple xrays • X-rays with the use of contrast media, UTZ, nuclear scans, imaging through computed tomography and MRI

UTZ • Ultras ound= KUB as sessment • Ful l bl adder duri ng the test • Previ ous bar ium studi es may af fect the test • Usef ul in di fferenti ati ng between soli d and fluid filled mass • Det ect m ass, obs tructi on and mal form ati ons

Retrograde Urography • Alternative procedure if the client is allergic to injectable contrast medium • Contrast media is administered directly into the urinary tract via cystoscope rather than IV administration

Endoscope • Visualization via cystoscopy (direct visualization of the urinary bladder via cystoscope) • Used to evaluate recurrent UTI, vesicourethral reflux, and hematuria • After the test increase fluid intake and watch out for infection

Endoscopic Procedures • • • • • • • • • • • • • •

Endoscope=an illuminated optic/sight for visualization Scopy=visualization Cystoscopy=bladder Ureteroscopy=ureter Nephroscopy=renal pelvis Ureterorenoscopy=ureter to the level of calices Cystogram=radiograph produced by cystography Cystography=radiographic examination of the urinary bladder after introduction of a dye Cystourethrogram=radiograph produced by cystourethrography Cystourethrography=radiographic examination of the urinary bladder and urethra after introduction of a dye Ureterogram=injection of dye into the ureter Ureterography=radiologic visualization of the ureter using a dye Vesiculogram=introduction of contrast media into the deferent ducts Vesiculography=seminal vesicles and adjacent tissue

Intravenous Pyelography IVP or Excretory Urography

• Radiologic films KUB are taken after an injection of contrast media. • Can detect stone masses hematuria, obstruction and congenital anomalies • Check allergies from the contrast media, flushing, warmth and unpleasant, salty taste may be experienced when the dye is administered. • Monitor hydration after the IVP • NPO night before the test • Cleanse the bowel prior to the test

Renal Angiography or Renal Scan • Radiographic visualization of renal blood vessels, size, shape and function after an introduction of a contrast media • Used to evaluate renal tumors, vascular map pre-op and potential kidney donor • NPO 6-8 hours

MRI (with injection of contrast media) • To image renal anatomy • To diagnose tumors, infarcts, vascular malformations and other abnormalities • Patient is placed under a strong magnetic field • Test is similar to x-ray although it uses no radiation • Painless and lasts 15-30 minutes • No food or fluid restrictions • Contraindicated to patient with metal in and on the body: pacemakers, metallic clips, prosthetic heart valves • Claustrophobic patient must be noted

CT Computed Tomography • 100x sensitive to ordinary radiograph • Can evaluate kidneys, urinary tract trauma, transplanted kidney, renal calculi and infection, painless

Renal Biopsy • Supine position • Hold breath when the kidney is about to be punctured • Bleeding time must be checked before the test • Prone position after the test • Avoid palpation and manipulation on the area • Avoid strenuous activity 2-3 weeks after the test • Monitor complication: • Colicky pain=clot in the ureter • Flank pain=bleeding in the muscle • Evaluate hematuria=collect serial urine specimen

Dialysi s To substi tute ki dney excretor y functi ons duri ng renal f ai lure

Types of Dialysis 1. Peritoneal

2. Hemodialysis

Peritoneal Dialysis • Intermittent peritoneal dialysis=acute or chronic renal failure • Continuous ambulatory peritoneal dialysis=chronic renal failure • Continuous cycling peritoneal dialysis=prolonged dwelling time • Indwelling catheter is implanted in the peritoneum • A connecting tube is attached to the external end of peritoneal catheter • T tube (tenckhoff, swan, cruz)

Peritoneal Dialysis • • • • • • •

Plastic bag of dialysate solution is inserted to the other end of T tube the other end is recap Dialysate bag is raised to shoulder level and infused by gravity in the peritoneal cavity (infusion time=10 min/2 L) Dwelling time 4-6 hours (depending on doctor’s order) At the end of dwelling time dialysis fluid is drained from the peritoneal cavity by gravity (draining time-10-20 min/2 L) Then repeat the procedure when necessary

Peritoneal Dialysis • NOTE : • Dialysis solution must be room-warmed before use (for better filtration and to lessen abdominal cramping) • Drugs (heparin, potassium and antibiotics) must be added in advance • Allow the solution to remain in the peritoneal cavity for the prescribed time • Check outflow (effluent) for cloudiness, blood and fibrin (early peritonitis) • Never push the catheter in

Peritoneal Dialysis • NOTE : • Monitor vital signs regularly • Keep a record of patient’s fluid balance (daily weighing) • Monitor blood chemistry • Turn the patient side to side if drainage stopped. • Observe for abdominal pain (cold solution) dialysate leakage • (prevent infection) • Intake must be equal to output or a liitlehigher (200ml)

“SI ESTA ”

Hemodialysis • A process of cleansing the blood (accumulated waste products) • Patient’s access is prepared and cannulated (surgically) • One needle is inserted to the artery (brachial) then blood flow is • directed to dialyzer (dialysis machine) • The machine is equipped with semi-permeable membrane surrounded with dialysis solution • Waste products in the blood move to the dialysis solution passing through the membrane by means of diffusion • Excess water is also removed from the blood by way of ultrafiltration • The blood is then returned to the vein after it has been cleansed

HEMODIALYSIS

Hemodialysis • NOT E: • Blood can be heparinized unless it is contraindicated (bleeding tendency) • Dialysis solution has some electrolytes and acetate and HCO3 are added to achieve proper pH balance • Methods of circulatory access • arteriovenous fistula • arteriovenous graft or U tube (polytetrafluoroethylene)

Hemodialysis • NOT E: • Assess the access site for bruit sounds (through auscultation) • Absence of thrill=may indicate occlusion (through palpation) • Assess neurovascular condition distal to the site • No BP taking on the access site • Cover the access site with adhesive bandage (dry sterile dressing) • Dietary adjustments of protein, sodium, potassium and fluid intake • Monitor vital signs regularly • Check blood chemistry • Constant monitoring of hemodynamic status, electrolytes and acid base balance • Start low flow rate, watchout dialysis disequilibrium) • 250 ml/hr (rate), 3-4 hours duration

Than k yo u!