CHARACTERISTICS OF NORMAL URINE

• Color: Normally pale yellow to amber

• Appearance: Clear.
• Odor: Faintly aromatic
• Specific Gravity: 1.010-1.025
• pH: 4.5-8 (average 6)
• Glucose, Ketones & Protein: Normally absent
• Sediments: None
• Bacteria & Pus: None
• RBC & WBC: None to trace amount (0-5hpf)

Cystoscopy
➢ Use of a lighted scope (cystoscope) to allow direct visualization of the urethra and
bladder.
➢ Inserted into the bladder via the urethra making it possible to see tumors, calculi,
ulcers, or other defects.
➢ May be used to remove tumors, stones, or other foreign materials or to implant
radium, place catheters in ureters. Cup forceps can be inserted through the
cystoscope for biopsy.
Nursing Care (pretest)
▪ Explain to the client that the procedure will be done under
general/local anesthesia.
▪ Instruct the patient to remain very still during the examination to
avoid urinary tract trauma.
▪ Obtain consent
▪ Inform that desire to void is felt during the examination
▪ The patient’s genitalia is cleansed with an antiseptic solution just
before the examination. A local topical anesthetic (lidocaine gel) is
instilled into the urethra before insertion of the cystoscope.
▪ Administer sedatives 1 hour before the test, as ordered.
▪ Place the patient in a lithotomy position
▪ Deep breathing to decrease discomfort as the cystoscope is
introduced
Nursing Care (post-test)
▪ Bed rest until vital signs are stable
▪ Pink Tinged urine is expected (24 – 48 hours) but bright red urine or
the presence of clots should be reported
▪ Advise the client that severe burning on urination is normal due to
tissue irritation and will subside.
▪ Observe for Urine retention, signs of infection, and
prolonged/excessive hematuria.
▪ Administer sitz baths for pelvic, back & abdominal pain.
▪ Force fluid to help prevent further tissue irritation by diluting the urine and
to prevent ascending UTI.
 RENAL ANGIOGRAPHY
Nursing care (pretest)
1. Obtain consent.
2. Assess allergies.
3. NPO post-midnight.
4. Laxative.
Nursing Care (posttest)
1. Bed rest.
2. Monitor vital signs for evidence
of internal bleeding.
3. Check for bleeding at puncture
site.
4. Check for proper circulation.
5. Increase fluid intake.

URINARY TRACT INFECTION (UTI).

Classification
1. Upper UTI The upper urinary tract includes the
kidneys and ureters. The lower urinary
2. Lower UTI tract includes the bladder and urethra.

Dysuria
Frequency & urgency
Suprapubic pain

Incidence: Women

Predisposing Factor
1. Urinary obstruction.
2. Bladder over distention.
3. Urinary reflux.
4. Fecal soiling of urethral meatus
5. Urinary tract instrumentation.
6. Pregnancy.
7. DM.
8. Sexual intercourse.
Clinical Manifestations
1. Acute pyelonephritis
 a. Flank Pain.
b. Costovertebral angle
tenderness.
c. Fever
d. Dysuria.
e. Frequency & urgency.
f. Bloody or cloudy urine
Medical Management
1. Antimicrobial therapy
a. Co-trimoxazole.
b. Ciprofloxacin
c. Cephalexin
2. Analgesic
a. Phenazopyridine HCL
(Pyridium).
3. Anticholinergics
(antispasmodic).
a. Propantheline Bromide
Benign prostatic
Prostate G and BPH hyperplasia (BPH) is
the term used to
describe a non-
Hormonal Imbalance malignant overgrowth
(Estrogen>Androgen) of the prostate gland.
↓ Specifically, the
proliferation of the
Hyperplasia. epithelial and smooth
↓ muscle cells in the
prostatic transition
Urinary obstruction. zone gives rise to this
↓ enlargement.

Urinary Reflux
↓
Hydroureter.
↓
Hydronephrosis.
Nor a prostate PH ↓
Renal
Insufficiency/Damage/Fai
lure.

C inica Manifestations
1. Obstructive symptoms
a. Nocturia.
 b. Decrease urinary stream.
c. Hesitancy.
d. Dribbling.
2. Signs & symptoms of urinary stasis
and infection.
3. Renal symptoms.
a. Hydroureter. when the ureter gets bigger than normal due to a
backup of urine (pee).

b. Renal insufficiency.
c. Hydronephrosis. the swelling of a kidney due to a build-up
of urine.
d. Uremia a clinical condition associated with worsening renal
function. It is characterized by fluid, electrolyte,
Medica Manage ent hormonal, and metabolic abnormalities.

1. Catheterization.
also known as dihydrotestosterone
2. 5 alpha-reductase inhibitors (finasteride, blockers, are a class of medications
with antiandrogenic effects which
dutasteride). are used primarily in the treatment
of enlarged prostate and scalp hair
3. Alpha- adrenergic blockers. (also called alpha-blockers) are a family of agents that bind
to and inhibit type 1 alpha-adrenergic receptors and thus
inhibit smooth muscle contraction. Their major uses are for
hypertension and for symptomatic benign prostatic
hypertrophy.
Nursing Management
1. Advise patient to:
a. Void whenever the urge to do is felt.
b. Avoid taking large quantities of fluid over
short period of time.
c. Avoid alcohol.
2. Prostatic massage
3. Sexual intercourse
4. Hot sitz bath

Transurethra Resection of the Prostate. Continuous adder Irrigation

Laboratory and Diagnostic Test
URINE STUDIES
1. Urinalysis: examination to assess the nature of the urine produced.
2. Urine Culture and sensitivity: diagnose bacterial infections of the urinary tract. Requires a
midstream clean catch urine specimen.
3. Creatinine Clearance: determines the amount of creatinine (a waste product of protein
breakdown) in the urine over 24 hours. Measures overall renal function; measures GFR.

URINE COLLECTION METHODS

1. Routine Urinalysis: an examination of the constituents of a sample of urine to establish a

baseline, to provide data for diagnosis, or to monitor results of treatment.
⚫ Female may be asked to wash the perineal area to clean away any collected debris.
⚫ Obtain first voided morning specimen in a clean container
⚫ Send to the laboratory immediately. It should be examined within 1 hour of voiding

2. Clean-Catch (Midstream) Specimen for Urine Culture: a culture of a urine sample to identify
the causative organism of a urinary tract infection (UTI).
⚫ Cleanse the perineal area.
Female: spread labia and cleanse meatus front to back using antiseptic sponges
because the urethral orifice is colonized by bacteria. Do not use sponges more than
once and then rinse the antiseptic solution thoroughly.
Male: Retract foreskin (if uncircumcised) and cleanse glans with antiseptic sponges and
rinse thoroughly.
⚫ Allow the initial urinary flow to escape to wash away urethral contaminants.
⚫ Collect the midstream urine specimen in a sterile container.
⚫ Have the client complete urination, but not in the specimen container.
⚫ Send the specimen to the laboratory immediately to avoid multiplication of urinary
bacteria and lysis of cells

3. 24-hour Urine Specimen

- The preferred method for creatinine clearance test.
⚫ Have client void and discard specimen; note the time.
⚫ Collect all subsequent urine specimens for 24 hours in a large container.
⚫ If the specimen is accidentally discarded, the test must be restarted.
⚫ Record exact start and finish of collection; include date and time.
Summary
The urinary system consists of the two kidneys, two ureters, the urinary bladder,
and the urethra. The kidneys are the principal regulators of the internal environment of
the body. The composition of all body fluids is either directly or indirectly regulated by
the kidneys as they form urine from blood plasma. The kidneys form urine to excrete
waste products and to regulate the volume, electrolytes, and pH of blood and tissue
fluids.
Urinary tract infections are very common and are a leading complication among
hospitalized individuals. Short-course antibiotic therapy is appropriate for
uncomplicated infections of the lower urinary tract that are not associated with the
presence of an indwelling urinary catheter. Teach people about perineal hygiene and
the importance of maintaining adequate fluid intake as measures to help prevent UTI.
Urinary calculi can obstruct the urinary tract at any level and cause significant
pain as they move from the kidney through the ureter. Instruct those who have had a
renal stone to maintain a generous fluid intake particularly during exercise and warm
weather, to reduce the risk of further stone formation.
BPH is a common condition as men get older. An enlarged prostate gland can
cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the
bladder. It can also cause bladder, urinary tract, or kidney problems.
SAMPLE QUESTIONS

1. Which classification of urinary tract infection (UTI) is described as an infection of the

renal parenchyma, renal pelvis, and ureters?
a. Upper UTI c. Complicated UTI
b. Lower UTI d. Uncomplicated UTI
2. While caring for a 77-year-old woman who has a urinary catheter, the nurse monitors
the patient for the development of a UTI. What clinical manifestations is the patient most
likely to experience?
a. Cloudy urine and fever
b. Urethral burning and bloody urine
c. Vague abdominal discomfort and disorientation
d. Suprapubic pain and a slight decline in body temperature
3. A woman with no history of UTIs who is experiencing urgency, frequency, and dysuria
comes to the clinic, where a dipstick and microscopic urinalysis indicate bacteriuria. What
should the nurse anticipate for this patient?
a. Obtaining a clean-catch midstream urine specimen for culture and sensitivity
b. No treatment with medication unless she develops fever, chills, and flank pain
c. Empirical treatment with trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim)
for 3 days
d. Need to have a blood specimen drawn for a complete blood count (CBC) and
kidney function tests
4. A female patient with a UTI has a nursing diagnosis of risk for infection related to a lack
of knowledge regarding the prevention of recurrence. What should the nurse include in
the teaching plan instructions for this patient?
a. Empty the bladder at least 4 times a day.
b. Drink at least 2 quarts of water every day.
c. Wait to urinate until the urge is very intense.
d. Clean the urinary meatus with an anti-infective agent after voiding.
5. Which characteristic is more likely with acute pyelonephritis than with a lower UTI?
a. Fever c. Urgency
b. Dysuria d. Frequency
6. Which test is required for a diagnosis of pyelonephritis?
a. Renal biopsy c. Intravenous pyelogram (IVP)
b. Blood culture d. Urine for culture and
sensitivity
7. Glomerulonephritis is characterized by glomerular damage caused by:
a. growth of microorganisms in the glomeruli.
b. release of bacterial substances toxic to the glomeruli.
c. accumulation of immune complexes in the glomeruli.
d. hemolysis of red blood cells circulating in the glomeruli.
8. What manifestation in the patient will indicate the need for restriction of dietary protein
in the management of acute post-streptococcal glomerulonephritis (APSGN)?
a. Hematuria c. Hypertension
b. Proteinuria d. Elevated blood urea nitrogen
(BUN)
9. What results in the edema associated with nephrotic syndrome?
a. Hypercoagulability c. Decreased plasma oncotic
pressure
b. Hyperalbuminemia d. Decreased glomerular
filtration rate
10. Number in sequence the following ascending pathologic changes that occur in the urinary
tract in the presence of a bladder outlet obstruction.
a. Hydronephrosis e. Renal atrophy
b. Reflux of urine into ureter f. Vesicoureteral reflux
c. Bladder detrusor muscle hypertrophy g. Large residual urine in the
bladder
d. Ureteral dilation h. Chronic pyelonephritis
11. What can patients at risk for renal lithiasis do to prevent the stones in many cases?
a. Lead an active lifestyle c. Drink enough fluids to
produce dilute urine
b. Limit protein and acidic foods in the diet d. Take prophylactic antibiotics
to control UTIs
12. Which type of urinary tract calculi are the most common and frequently obstruct the
ureter?
a. Cystine c. Calcium oxalate
b. Uric acid d. Calcium phosphate
13. On the assessment of the patient with a renal calculus passing down the ureter, what
should the nurse expect the patient to report?
a. A history of chronic UTIs
b. Dull, costovertebral flank pain
c. Severe, colicky back pain radiating to the groin
d. A feeling of bladder fullness with urgency and frequency
14. Prevention of calcium oxalate stones would include dietary restriction of which foods or
drinks?
a. Milk and milk products c. Liver, kidney, and
sweetbreads
b. Dried beans and dried fruits d. Spinach, cabbage, and
tomatoes
15. Priority Decision: Following electrohydraulic lithotripsy for treatment of renal calculi, the
patient has a nursing diagnosis of risk for infection related to the introduction of bacteria
following manipulation of the urinary tract. What is the most appropriate nursing
intervention for this patient?
a. Monitor for hematuria. c. Apply moist heat to
the flank area.
b. Encourage fluid intake of 3 L/day. d. Strain all urine through gauze or a
special strainer.
Key Answer and Rationale:
1. a. An upper urinary tract infection (UTI) affects the renal parenchyma, renal pelvis, and
ureters. A lower UTI is an infection of the bladder and/or urethra. A complicated UTI exists
in the presence of obstruction, stones, or preexisting diseases. An uncomplicated UTI occurs
in an otherwise normal urinary tract.
2. c. The usual classic manifestations of UTI are often absent in older adults, who tend to
experience nonlocalized abdominal discomfort and cognitive impairment characterized by
confusion or decreased level of consciousness rather than dysuria and suprapubic pain.
3. c. Unless a patient has a history of recurrent UTIs or a complicated UTI, trimethoprim-
sulfamethoxazole (TMP-SMX) or nitrofurantoin (Macrodantin) is usually used to empirically
treat an initial UTI without a culture and sensitivity or other testing. Asymptomatic bacteriuria
does not justify treatment but symptomatic UTIs should always be treated.
4. b. The bladder should be emptied at least every 3 to 4 hours. Fluid intake should be increased
to about 2000 mL/ day without caffeine, alcohol, citrus juices, and chocolate drinks because
they are potential bladder irritants. Cleaning the urinary meatus with an anti-infective agent
after voiding will irritate the meatus but the perineal area should be wiped from front to back
after urination and defecation to prevent fecal contamination of the meatus.
5. a. Systemic manifestations of fever and chills with leukocytosis and nausea and vomiting are
more common in pyelonephritis than in a lower UTI. Dysuria, frequency, and urgency can be
present with both.
6. d. A urine specimen specifically obtained for culture and sensitivity is required to diagnose
pyelonephritis because it will show pyuria, the specific bacteriuria, and what drug the bacteria
is sensitive to for treatment. The renal biopsy is used to diagnose chronic pyelonephritis or
cancer. Blood cultures would be done if bacteremia is suspected. Intravenous pyelogram
(IVP) would increase renal irritation, but CT urograms may be used to assess for signs of
infection in the kidney and complications of pyelonephritis.
7. c. Glomerulonephritis is not an infection but rather an antibody-induced injury to the
glomerulus, where either autoantibody against the glomerular basement membrane (GBM)
directly damages the tissue or antibodies reacting with non-glomerular antigens are
randomly deposited as immune complexes along the GBM. Prior infection by bacteria or
viruses may stimulate the antibody production but is not present or active at the time of
glomerular damage.
8. d. An elevated blood urea nitrogen (BUN) indicates that the kidneys are not clearing
nitrogenous wastes from the blood and protein may be restricted until the kidney recovers.
Proteinuria indicates the loss of protein from the blood and possibly a need for increased
protein intake. Hypertension is treated with sodium and fluid restriction, diuretics, and
antihypertensive drugs. The hematuria is not specifically treated.
9. c. The massive proteinuria that results from increased glomerular membrane permeability in
nephrotic syndrome leaves the blood without adequate proteins (hypoalbuminemia) to create
an oncotic colloidal pressure to hold fluid in the vessels. Without oncotic pressure, fluid moves
into the interstitium, causing severe edema. Hypercoagulability occurs in nephrotic syndrome
but is not a factor in edema formation and glomerular filtration rate (GFR) is not necessarily
affected in nephrotic syndrome.
10. c. Because crystallization of stone constituents can precipitate and unite to form a stone
when in supersaturated concentrations, one of the best ways to prevent stones of any type
is by drinking adequate fluids to keep the urine dilute and flowing (e.g., an output of about
2 L of urine a day). A sedentary lifestyle is a risk factor for renal stones but exercise also
causes fluid loss and a need for additional fluids. Protein foods high in purine should be
restricted only for the small percentage of patients with uric acid stones and although UTIs
contribute to stone formation, prophylactic antibiotics are not indicated.
11. c. Calcium oxalate calculi are most common and small enough to get trapped in the ureter.
12. c. A classic sign of the passage of a calculus down the ureter is intense, colicky back pain
that may radiate into the testicles, labia, or groin and may be accompanied by mild shock
with cool, moist skin. Many patients with renal stones do not have a history of chronic UTIs.
Stones obstructing a calyx or at the ureteropelvic junction may produce dull costovertebral
flank pain and large bladder stones may cause bladder fullness and lower obstructive
symptoms.
13. d. Oxalate-rich foods should be limited to reduce oxalate excretion. Foods high in oxalate
include spinach, rhubarb, asparagus, cabbage, and tomatoes, in addition to chocolate, coffee,
 and cocoa. Currently, it is believed that high dietary calcium intake may actually lower the
risk for renal stones by reducing the intestinal oxalate absorption and therefore the urinary
excretion of oxalate. Milk, milk products, dried beans, and dried fruits are high sources of
calcium. Organ meats are high in purine, which contributes to uric acid lithiasis.
14. b. A high fluid intake maintains dilute urine, which decreases bacterial concentration in
addition to washing stone fragments and expected blood through the urinary system
following lithotripsy. High urine output also prevents the supersaturation of minerals. Moist
heat to the flank may be helpful to relieve muscle spasms during renal colic and all urine
should be strained in patients with renal stones to collect and identify stone composition but
these are not related to infection.
15. b. Output from ureteral catheters must be monitored every 1 to 2 hours because an
obstruction will cause an overdistention of the renal pelvis and renal damage. The renal pelvis
has a capacity of only 3 to 5 mL and if irrigation is ordered, no more than 5 mL of sterile
saline is used. The patient with a ureteral catheter is usually kept on bed rest until specific
orders for ambulation are given. Suprapubic tubes may be milked to prevent obstruction of
the catheter by sediment and clots.

Scrub Nurse
• Set up sterile tables, supplies, and instruments.
• Preparing sutures, ligatures, and special equipment.
• Assists the surgeon & the surgical assistant
• Assists in gowning and gloving of the surgical team
• Assists in draping
• Hands sterile instruments, sutures, sponges to the surgeon during the procedure
• Keeps a close watch on needles, instruments, and sponges
• Count and keep accurate needle/instrument count with the circulating nurse as the surgical
incision is closed.
• Label tissue specimens obtained during the surgery.
• Discards soil linen
 Circu ating Nurse
• Coordinates & documents patients care in the operating room
• Verify the consent
• Coordinates the team and ensuring cleanliness, proper temperature, humidity, a safe function
of the equipment, and the availability of supplies and materials (overseer of the room during
operation)
• Monitor aseptic practices
• Sends for the patient at the appropriate time
• Receives, greets, identifies the patient
• Check chart for completeness
• Checks operating room lights in advance for good working order
• Prepares operative site
• Does sponge count with the scrub nurse
• Fills out required operation records completely and legibly
Anesthesio ogist
• Gives & controls the anesthesia for the patient
• Gives signal to the surgeon or circulating nurse to proceed with positioning and preparing the
operative site
• Continuously monitors the person’s physiological status such as monitoring vital sign during
operation
• Informs the surgeon about the patient’s condition and alerts the surgeon to developing problems
and treats them as they arise
• Determine when the patient may be moved to RR/PACU after the operation has been completed
Surgica (OR) attire
To provide infection control within the operating room and to reduce cross-contamination between the
surgery department and other hospital units or departments.
• a. Scrub attire includes a scrub suit, shoe covers, and cap or hood to cover hair.
• b. Sterile attire includes scrub suit, shoe covers, and cap or hood, plus gown, gloves, and
mask

asic E e ents of Anesthesia

• Loss of Consciousness
• Analgesia.
• Hypnosis.
• Muscle relaxation.

Stages of Genera Anesthesia

• Beginning: extends from the administration of anesthesia to the time of loss of consciousness.
• Excitement: extends from loss of consciousness to the time of loss of lid reflex. It is characterized
by struggling and shouting.
• Surgical anesthesia: extends from the loss of lid reflex to loss of most reflexes.
• Medullary depression: characterized by respiratory and cardiac depression or arrest.

Phases of Perioperative Nursing

1. Preoperative phase: starts from the time the decision is made for surgical intervention to the
transference of the patient to the operating room.
2. Intraoperative phase: starts from the time the patient is received in the operating room until
he is admitted to the recovery room or post-anesthesia care unit (PACU).
3. Postoperative phase: starts from the time of admission to the recovery room or PACU to the
follow-up home or clinic evaluation.
Three Phases of the Postoperative Period
Phase I: Immediate Postoperative Period: Care given to the client in the Recovery Room
(RR) or Post-anesthesia Care Unit (PACU).
Phase II: Intermediate period: care given from the time of discharge from the post-
anesthesia care unit to the first day or two after surgery.
Phase III: Postoperative phase: time of healing, which may last for weeks, months, or
even years after surgery.
Classification of Surgical Procedures
Types According to PURPOSE

1. Diagnostic: to identify or confirm the presence of a disease condition (e.g. biopsy)

2. Exploratory: to determine the extent of the disease condition (e.g. exploratory
laparotomy)
3. Curative: to treat the disease condition. The different types of curative surgeries are:
a. Ablative: involves the removal of an organ (e.g. cholecystectomy,
appendectomy). Suffix used in these types of surgery is “ectomy”.
b. Constructive: involves repair of a congenitally defective organ (e.g. cheiloplasty,
uranoplasty, herniorrhaphy). Suffixes used in these types of surgery are “plasty,
orraphy, pexy”.
c. Reconstructive: involves repair of a damaged organ (e.g. skin grafting or plastic
surgery after burns, total joint replacement)
4. Transplant: replace organs/tissue to restore function (e.g. Heart, lung, liver, kidney
transplant)
5. Palliative: to relieve distressing signs and symptoms, not necessarily to cure the
disease (e.g. to relieve pain or correct a problem—for instance, a gastrostomy tube
may be inserted to compensate for the inability to swallow food, colostomy to bypass
an obstruction, resection of nerve roots to relived pain).
6. Cosmetic: focused on enhancing appearance (e.g. mammoplasty or a facelift)

Types According to the Degree of RISK/ MAGNITUDE

1. Major Surgery: involves a high degree of risk, it may be complicated or prolonged, large
losses of blood may occur, vital organs may be involved or postoperative complications
may be likely (e.g. open-heart surgery, craniotomy)
2. Minor Surgery: involves few complications, lower risk, and generally the procedure is
not prolonged (e.g. breast biopsy, tonsillectomy)

Types According to URGENCY

1. Optional: surgery is scheduled at the preference of the patient; decision rest with the
patient (e.g. cosmetic surgery like breast enhancement)
2. Elective: the approximate time for surgery is at the convenience of the patient. The
failure for not having the surgery is not catastrophic (e.g. repair of scars, vaginal repair,
superficial cyst removal)
3. Required: the condition requires surgery within a few weeks or months (e.g. cataract
operation)
4. Urgent or Imperative: surgical problem requires prompt attention within 24 hours to 30
hours (e.g. kidney or ureteral stones, acute gallbladder infection, heart bypass surgery)
5. Emergent: requires immediate surgical attention without delay; disorder may be life-
threatening (e.g. severe bleeding, bladder or intestinal obstruction, fractured skull,
gunshot or stab wounds, ruptured aneurysm)

Types According to SURGICAL SETTING

1. Ambulatory Surgery (outpatient surgery): a surgical intervention that does not require
an overnight hospital stay, can leave soon after the intervention or short stay, with
admission to an inpatient hospital setting for less than 24 hours. The advantages of
outpatient surgeries are to lower hospitalization costs, save patients’ time, and less
evidence of hospital-acquired infection. Examples are dilation and curettage, tubal
ligation, myringotomy, excision of skin lesion, and oral surgery.
2. ln-patient Surgery: a surgical intervention after which the patient has to spend one or
several nights in the hospital, where they will receive permanent postoperative care, and
their recovery will be carefully monitored. Patients who need to undergo complex surgery
or a procedure that entails a prolonged recovery period will often receive inpatient care.

Principles of Surgical Asepsis

1. All items in the OR must be sterile.
 2. All personnel must perform a surgical scrub and wear a sterile mask gown and gloves.
Gowns of the surgical team are considered sterile in front of the chest to the level of the
sterile field. The sleeves are considered sterile from 2 inches above the elbow to the
stockinette cuff.
3. Sterile, scrubbed personnel should touch only sterile items. The movements of the
surgical team are from sterile-to-sterile areas and from unsterile-to-unsterile areas.
4. Sterile gown and sterile drapes have defined borders of sterility
5. That which is used for one client must be discarded or, in some cases sterilize
6. The circulator and unsterile personnel must stay in the periphery of the sterile operating
area in order not to contaminate the sterile area. Whenever a sterile barrier is breached,
the area must be considered contaminated
7. Sterile supplies are unwrapped and deliver by the circulator following specific standard
protocol so as not cause contamination
8. The utmost caution and vigilance must be used when handling sterile fluids to prevent
splashing or spillage.
9. OR personnel must practice strict universal precautions
10. Items of doubtful sterility are considered unsterile.

Cleaning, Disinfection, and Sterilization

Cleaning: the physical removal of blood, body fluids, and or gross debris from the inanimate
object.
Disinfection: the destruction of pathogenic microorganisms or their toxins or vectors by direct
exposure to chemicals or physical agents. There are three levels of disinfection:
➢ High-level disinfection. Kills all microorganisms except spores and may kill certain spores
with sufficient contact time. Only sterilization ensures that all spores are killed. High-
level disinfectants: glutaraldehyde (Cidex); 6 % hydrogen peroxide; peracetic acid;
chlorine compounds (house bleach).
➢ Intermediate-level disinfection. Kills most microorganisms except spores. Intermediate-
level of disinfectants: alcohol; iodophors.
➢ Low-level disinfection. Kills bacteria, fungi, and hydrophilic viruses, but is not effective
against spores like mycobacterium tuberculosis. Low-level disinfectants: quaternary
ammonium compounds.
Sterilization: the destruction of all microorganisms in or about an object, such as by steam,
chemical agents, or ultraviolet radiation.

Surgical Incisions
Butterfly Incision for craniotomy
Limbal Incision for eye surgeries
Halstead/ Elliptical Incision for breast surgery
Abdominal Incision
a. Subcostal, Upper Quadrant Oblique Incision: A right
or left oblique incision begins in the epigastrium &
extends laterally & obliquely just below the lower
costal margin
b. Paramedian: vertical incision about 4-cm lateral to
the midline in either side on the upper or lower
abdomen.
c. Mid-abdominal Transverse: start on either left or
right side slightly above or below the umbilicus.
d. Mc Burney’s: area just below the umbilicus and 4 cm
medial from the anterior superior iliac spine.
e. Longitudinal Midline:
i. Upper midline: exposure of the upper abdominal
content.
ii. Lower midline: provide exposure to the pelvic
organs.
 f. Pfannenstiel: is a curved transverse incision across
the lower abdomen within the hairline of the pubis.
Collar Incision for thyroidectomy
Sternal Incision for cardiac procedures
Lumbotomy or Transverse Incision for kidney surgeries

Functions of Body Water

1. Maintains blood volume
2. Transport gases, nutrients & other substances to and from the cell
3. Internal aqueous medium for the cellular chemical function
4. Maintenance of normal body temperature
5. Elimination of waste products from the cells

Electrolytes: chemical compounds in solution that can conduct an electrical current. Break into
charged particles called ions.
➢ Potassium (K+) and Phosphate (PO4-) are the major electrolytes in ICF.
➢ Sodium (Na+) and chloride (Cl-) are the major electrolytes in EFC.

Normal Laboratory Values for Electrolytes

Na+ : 135-145 mEq/L Cl- : 98-108 mEq/L
K+ : 3.5-5 mEq/L Mg2+ : 1.5-2.5 mEq/L or 1.3-
2.3 mg/dl
Ca2+ : 4.5-5.5 mEq/L or 8.6-10.2 mg/dl Phosphorous: 1.8-4.6 mEq/L or
2.5-4.5 mg/dl

Functions of Electrolytes in the Body

1. Promote neuromuscular irritability
2. Maintain body fluid volume and osmolality
3. Distribute body water between fluid compartments
4. Regulate acid-base balance
Sodium and Water Regulation
➢ Thirst: major control of actual fluid intake
➢ Kidneys: major organs controlling output
➢ ADH: retains water in the renal tubules in the kidney
➢ RAAS: aldosterone retains sodium and water in the kidney
➢ ANS (atrial natriuretic peptide): excrete sodium and water in the kidney

Potassium Regulation
➢ Aldosterone and hydrogen ions regulate potassium levels.
➢ Aldosterone retains sodium and excretes potassium (aldosterone is pro-Na+, and anti-
K+)
➢ Alkalosis increases potassium excretion & Acidosis decreases potassium excretion.
➢ Potassium is the major cation in the ICF & is necessary for the conduction of nerve
impulses and the promotion of skeletal and cardiac muscle activity.

Calcium Regulation: parathormone, thyrocalcitonin, and Vitamin D regulate calcium levels.

➢ Parathormone elevates serum calcium levels through the withdrawal of calcium from the
bones or bone resorption.
➢ Thyrocalcitonin lowers serum calcium levels by depositing calcium into the bones.
➢ Vitamin D promotes calcium absorption.
➢ Calcium is necessary for normal transmission of impulses, muscle contraction, blood
clotting, and the development of bone and teeth.
 Fluid Imbalances
Fluid Volume Deficit (Hypovolemia)

➢ Nursing Management
⚫ Administer oral fluids
⚫ Monitor intake and output (I&O) at least every 8 hours
⚫ Weigh the patient daily
⚫ Monitor for symptoms: skin & tongue turgor, mucosa, urinary output
(UO), & mental status
⚫ Initiate measures to minimize fluid loss by treating the cause
⚫ Provide oral care
⚫ Administer parenteral fluids as ordered by the doctor.

Fluid Volume Excess (Hypervolemia)

➢ Nursing Management
• Take I & O and daily weights; assess for lung sounds, edema, and other
symptoms; monitor responses to medications such as diuretics
• Promote adherence to fluid restrictions and patient teaching related to
sodium and fluid restrictions
• Monitor and avoid sources of excessive sodium; include medications
• Promote rest and use semi-Fowler’s position for orthopnea
• Provide skincare and positioning/turning

Electrolyte Imbalances
1. Hyponatremia (sodium deficiency): serum sodium level below 135 mEq/L resulting
from excessive sodium loss or excessive water gain.

➢ Nursing management
• Assessment: I&O, daily weight, lab values, and CNS changes
• Encourage sodium-rich foods
• Identification and monitoring of at-risk patients and the effects of
medications (diuretics and lithium)
• Safety precautions

2. Hypernatremia (Sodium excess): serum sodium level above 145 mEq/L due to a gain
of sodium in excess of water or a loss of water in excess of sodium.

➢Nursing Management
• Monitor intake and output
• Restrict sodium in diet
• Increase oral fluids
• Promote safety, monitor behavior changes
Potassium Imbalances
Hypokalemia (Potassium deficit): serum potassium level below 3.5 mEq/L.

➢ Nursing Management
• Assessment (severe hypokalemia is life-threatening), monitoring of
electrocardiogram (ECG), arterial blood gases (ABGs), and providing
nursing care related to IV potassium administration.
• Potassium-rich food (apricot, banana, cantaloupe, dates, dried fruits,
orange, raw carrots, raw tomato, baked potato, watermelon. Fresh fruits
in general have potassium content except for apple.
• Nurse Alert: administer potassium supplement (potassium chloride) per
slow IV drip since it may cause dysrhythmias and cardiac arrest.
Hyperkalemia (Potassium excess): serum potassium level above 5.0 mEq/L.

➢ Nursing Management
• Assess serum potassium levels
• Monitor I & O and observes for signs of dysrhythmias.
• Low potassium diet and dietary teaching
Calcium Imbalances
Hypocalcemia (Calcium deficiency): serum calcium level below 8.6 mg/dL. Serum calcium level
controlled by parathyroid hormone and calcitonin.

➢ Nursing management
• High calcium diet (at least 1,000 to 1,500 mg/day in the adult is
recommended)
• Protect from trauma to prevent fracture
• Monitor breathing since laryngospasm my occur.
• Maintain a relaxed, quiet environment, and promote adequate rest.
• Promote safety if confusion is present.
• Educates patient that alcohol and caffeine in high doses inhibit calcium
absorption, and moderate cigarette smoking increases urinary calcium
excretion.

Hypercalcemia (calcium excess): serum calcium level above 10.5 mg/dL.

➢ Nursing Management
• Increase fluid intake (3 to 4 L/day) to prevent dehydration
• Provide acid ash fruit juices and vitamin C to acidify the urine and prevent
renal stone formation
• Protect the client from injury
a. Keeping bedside rails up
b. Keeping the brakes locked
c. Repositioning often
d. Securing all invasive lines
• Provide client teaching the importance of early ambulation and daily
weight-bearing activities during hospitalization.
• Adequate fiber in the diet is encouraged to offset the tendency for
constipation

Magnesium Imbalances
Hypomagnesemia (magnesium deficiency): serum magnesium level below 1.5 mEq/L

➢ Nursing Management
• Provide foods rich in magnesium (meat, milk, fruits, green vegetables,
whole grain cereals, nuts, seafood).
• Promote safety, protect the client from injury.
• Monitor client for laryngeal stridor

Hypermagnesemia (magnesium excess): serum magnesium level above 2.5 mEq/L.

➢ Nursing Management
• Assess for signs and symptoms of hypermagnesemia especially DTRs and
changes in LOC
• Avoid administering medications containing magnesium
 Acid-Base Imbalances
1. Respiratory Acidosis (carbonic Acid Excess): caused by the failure of the respiratory
system to remove CO2 from the body fluid as it is produced in the tissues. Disorders that
lead to hypoventilation result in the retention of CO2.

➢ Collaborative Management: promote respiratory function

• Administer bronchodilators as prescribed
• Perform postural drainage as ordered
• Sodium bicarbonate per IV as prescribed if the client develops
hyperkalemia or ventricular fibrillation
2. Respiratory Alkalosis (Carbonic Acid Deficit): caused by loss of CO2 from the lungs at a
faster rate than is produced in the tissues. Disorders that lead to hyperventilation results
in the excess loss of CO2.

➢ Collaborative Management:
• Instruct the client to breathe into a plastic bag or brown paper bag.
• Treat the underlying cause.

3. Metabolic Acidosis (Bicarbonate Deficit): acid-base imbalance resulting from excessive

absorption or retention of acid or excessive excretion of bicarbonate (HCO 3).

➢ Collaborative Management
• Maintain good respiratory function
• Fluid replacement. Water loss may result from hyperventilation
• Protect the client from injury. Risk for injury related mental dullness.
• Restore electrolyte balance, especially potassium.
• Administer Sodium Bicarbonate per IV as prescribed
• Identify and treat the underlying cause (e.g., renal failure, DM,
starvation, ketoacidosis, shock, chronic diarrhea, ASA.
4. Metabolic Alkalosis (Bicarbonate Excess): acid-base imbalance characterized by
excessive loss of acid or excessive gain of HCO3.

➢ Collaborative Management
• Maintain respiratory function
• Protect the client from injury. Seizure may occur
• NaCl or Ammonium Chloride oral or intravenous
• Diamox (Acetazolamide). A carbonic anhydrase inhibitor that increases
the excretion of bicarbonate by the kidneys.
• Identify and treat the underlying cause (e.g., excess intake of sodium
bicarbonate or baking soda, vomiting, gastric suctioning, intestinal
fistulas.

Critical to Remember!!!
Respiratory and Metabolic Acidosis results in the following:
1. Hyperkalemia
2. CNS depression and may lead to coma
3. Cerebral vasodilation
4. Increased intracranial pressure (ICP)
5. Peripheral vasoconstriction
6. Increased blood pressure (hypertension)

Respiratory and Metabolic Alkalosis result in the following:

1. Hypokalemia
2. CNS stimulation and may lead to seizures
3. Cerebral vasoconstriction
4. Peripheral vasodilation
5. Hypotension
6. Destroy ionized calcium that leads to hypocalcemia
 ❖ Chemical buffers, lungs, and kidneys work together to maintain acid-base balance

Summary
The volume and composition of body fluid are normally maintained by a balance of fluid
and electrolyte intake; elimination of water, electrolytes, and acids by the kidneys; and
hormonal influences. Change in any of these factors can lead to a fluid, electrolyte, or acid-
base imbalance that adversely impacts health.
Fluid, electrolyte, and acid-base imbalances can affect all body systems, especially the
cardiovascular system, the central nervous system, and the transmission of nerve impulses.
Conversely, primary disorders of the respiratory, renal, endocrine, cardiovascular, or other body
systems can lead to an imbalance of fluids, electrolytes, or acid-base status.
Fluid and sodium imbalances commonly are related; both affect serum osmolality.
Potassium imbalances are commonly seen in a person with acute or chronic illnesses.
Both hypokalemia and hyperkalemia affect cardiac conduction and function. Careful monitoring
of cardiac rhythm and status in a person with very low or very high potassium levels is crucial.
Calcium imbalances primarily affect neuromuscular transmission: hypocalcemia
increases neuromuscular irritability; hypercalcemia depresses neuromuscular transmission.
Magnesium imbalances have a similar effect.
Acid-base imbalances may be caused by either metabolic or respiratory problems.
Simple acid-base imbalances (respiratory or metabolic acidosis or alkalosis) are more
commonly seen than mixed imbalances.
Buffers, lungs, and kidneys work together to maintain acid-base balance in the body.
Buffers respond to changes almost immediately; the lungs respond within minutes; the
kidneys, however, require hours to days to restore the normal acid-base balance.
 Renal stones are formed within the kidneys, and this is called nephrolithiasis. Urolithiasis is
a condition that occurs when these stones exit the renal pelvis and move into the remainder
of the urinary collecting system, which includes the ureters, bladder, and urethra.

Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are

hard deposits made of minerals and salts that form inside your kidneys.

Hemodialysis is a treatment to filter wastes and water from your blood, as your
kidneys did when they were healthy. Hemodialysis helps control blood pressure and
balance important minerals, such as potassium, sodium, and calcium, in your blood.g
Bladder cancer is a common type of cancer that begins in the cells of the bladder. The bladder is a hollow
muscular organ in your lower abdomen that stores urine. Bladder cancer most often begins in the cells
(urothelial cells) that line the inside of your bladder.

Types of bladder cancer

The type of bladder cancer depends on how the tumor’s cells look under the microscope. The 3 main types of
bladder cancer are:

Urothelial carcinoma. Urothelial carcinoma (or UCC) accounts for about 90% of all bladder cancers. It also accounts
for 10% to 15% of kidney cancers diagnosed in adults. It begins in the urothelial cells that line the urinary tract.
Urothelial carcinoma used to be called transitional cell carcinoma or TCC.

Squamous cell carcinoma. Squamous cells develop in the bladder lining in response to irritation and inflammation.
Over time, these cells may become cancerous. Squamous cell carcinoma accounts for about 4% of all bladder
cancers.

Adenocarcinoma. This type accounts for about 2% of all bladder cancers and develops from glandular cells.