N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 48 of 160 are the primary regulators of fluid and acid-base balance in the body. Aldosterone (released from the adrenal cortex) causes sodium and water to be reabsorbed in greater quantities, increasing blood volume and decreasing urine output. The bladder is a reservoir for urine and is an organ of excretion. The bladder wall is made up of four layers: inner mucous layer, connective tissue layer, three layers of smooth muscle fibers, and an outer serous layer. The voiding reflex center is located at the level of the second to fourth sacralvertebrae. The ureters carry urine from the renal pelvis to the bladder; the ureters are 10-12 inches long. The urethra leads from bladder neck to the external meatus. Abnormal urine will contain leukocytes if an infection is present. Red blood cells can be indicative of an infection, as well as possible cancers of the urinary tract or normal menstrual bleeding. Urine odors may be caused by foods (asparagus), infections or glucose. Freshly voided urine is slightly acidic, although a diet high in fruits and vegetables can cause an alkaline shift as does an infection. Glucose and ketones are indicative of diabetes or starvation. Nursing diagnosis • At risk for constipation related to decreased peristalsis secondary to inadequate fluid intake, inadequate fiber, or lack of exercise • Constipation related to decreased abdominal muscle tone secondary to aging or decreased mobility • Impaired urinary elimination related to weak pelvic floor muscles secondary to childbirth, aging, or obesity • Check for bowel incontinence, constipation, risk for constipation, perceived constipation, diarrhea • Risk for fluid volume deficit related to prolonged diarrhea/abnormal fluid loss throughostomy • Risk for impaired skin integrity related to prolonged diarrhea, bowel incontinence, or bowel diversionostomy • Self-esteem disturbance related to ostomy, fecal incontinence, or need for assistance with toileting • Knowledge deficit (bowel training or ostomy management) related to lack of previous experience • Anxiety related to lack of control of fecal elimination secondary to ostomy or response of others toostomy • Constipation related to decreased abdominal muscle tone associated with aging 2.7 Urinary Elimination The kidneys