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 x-

rays
• 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 liitle-
higher (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!