Group G

CHAPTER 20 - Urinary EliminationIntroductionUrinary habits depend on:social culturepersonal habitsphysical abilitiesPersonal habits are affected by:social propriety of leaving to urinateavailability of a private clean facilityinitial bladder trainingPhysiology of Urinary EliminationUpper urinary tract:kidneysuretersLower urinary tract:urinary bladderurethrapelvic floorKidneysTwo kidneys on either side of spinal columnRight kidney slightly lower (liver) Primary regulators of fluid and acid-base balanceNephrons - functional units of the kidneys; filter blood and remove metabolic wastes1200 mL or 21% of CO passes through kidney per minute1,000,000 nephrons per kidneyglomerulus - the part of a nephron that is a tuft of capillaries surrounded by Bowman’s capsuleglomerular filtrate = water, electrolytes, glucose, amino acids, and metabolic wastes. (plasma proteins and blood cells TOO big) Proximal Convoluted Tubule:Absorbed: water and electrolytes Loop of HenleAbsorbed: glucoseSecreted: other substances = concentrated urine Distal Convoluted Tubule: Absorbed: water and Naunder control of ADH (H20) and aldosterone (Sodium + H20). Collecting DuctUreterscollecting duct —> calyx of renal pelvis —> uretersureters10-12 inches long0.5 inches in diameterupper end is funnel shaped attached to kidneyslower end enters the bladder at posterior cornershas a valve at junction between ureters and bladder to prevent refluxreflux - backflowBladderBladdera hollow, muscular organreservoir for urineorgan of excretionwhen empty, it lies behind symphysis pubiswomen: in front of uterus and vagina men: in front of rectum and above prostate. Four layers:Inner mucous layerConnective tissue layerThree layers of smooth muscle (detrusor muscle)detrusor muscle - collectively, the three layers of smooth muscle fibers, some of which extend lengthwise, some obliquely, and some more or less circularly allows bladder to expand and contractOuter serous layer trigone - a triangular area marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior inferior cornerCapacity: 300mL to 600mL able to be distended because of rugae/folds, elasticity of wallswhen full, dome of the bladder may extend above symphysis pubis, even as high as umbilicusstimulated by 250mL and 450mLUrethraextends from bladder to urinary meatusmeatus - openingWomenlies directly behind symphysis pubis, anterior to vagina1.5 inches longonly for elmination of urinemeatus is between labia minor in front of vagina and below the clitorisprone to UTIs because of short urethra and proximity of meatus to vagina and anusMen8 inches longpassageway for semen and urinemeatus is at distal end of penismucous membrane is continuous with bladder and uretersinfection in urethra easily spread up the urinary tract to the kidneysPelvic Floorsheets of muscles and ligaments that provide support to the viscera of the pelvismuscles extend from symphysis pubis to coccyxcontinence mechanisminternal sphincter = involuntary controlexternal sphincter = voluntary controlUrinationmicturition/voiding/urination - the process of emptying the urinary bladderurine collects in the bladder until special nerve stimulation of stretch receptors on bladder wallusually occurs between 250mL- 450mL of urine. (50-200mL for children) stretch receptor impulses sent through spinal cord to voiding reflex center at S2-S4 causing internal sphincter to relax and stimulate urge to urinate conscious portion in charge of relaxing external sphincters to initiate urination. only possible if all nerves between bladder and urethra to the brain and motor area are all intact. cerebral hemorrhage or spinal cord injury = involuntary urinationolder adults w/ impaired cognition = unawareness of need to urinate or unable to respond to urge of urinationFactors Affecting VoidingDevelopmental FactorsInfantsvaries according to fluid intake250-500 mL/day during first yearurinate up to 20x/daycolorless, odorless, sp.gr. = 1.008 (cannot concentrate urine effectively)urinary control between 2-5 y/oPreschoolersindependent toilingaccidents occur, should not be punished for thisoften forget to wash their hands or flush, need instruction to wipegirls - teach them how to wipe from front to back to prevent contamination of the urinary tract by fecesSchool-Age Childrenelimination system reaches maturitykidneys double in size at 5-10 y/ourinates 6-8x/dayenuresis - the involuntary passing of urine when control should be established (about 5 years of age)10% of 6 y/o experience difficulty controlling their bladdernocturnal enuresis - bed-wetting; the involuntary passing of urine during sleepOlder AdultsPrerenal failure: hypertensionIntrarenal failure = hypertension, diabetes, toxinsPost renal failure = outflow obstructionDiminished excretory function Factors that impair renal function:arteriosclerosisconditions that alter normal fluid intake and outputhaving influenzasurgerymore susceptible to toxicity from medications due to decreased excretionUrinary urgency and frequency factors:men: enlarged prostate glanddouble void technique: empty bladder, after feeling done, try to void againwomen: weakness of muscle supporting bladderdecreased bladder capacity and ability to completely emptyretention of residual volume also predisposes to UTI. nocturnal frequency - the need for older adults to arise during the night to voidTABLE 1 Changes in Urinary Elimination Throughout the Life SpanFetusesbegins to excrete urine between 11-12 weeksInfantsminimal ability to concentrate urine, urine is light yellowvoluntary urinary control is absentChildrenkidney function matures at 1-2 y/o - effective concentration, normal amber color18-25 mos - able to recognize bladder fullness, hold urine beyond urge2.5-3 y/o - perceives bladder fullness, holds urine, communicates need to urinatefull control at 4-5 y/o; daytime control by 3 y/oAdultsmaximum kidney size @ 35-40 y/o>50 y/o - diminished kidney size and function; occurs in cortex as nephrons are lostOlder adults30% of nephrons lost by 80 y/odecreased renal blood flow due to vascular changes and decreased COability to concentrate urine declinesbladder tone diminishes - urinary frequency, nocturiamay lead to residual urine, increasing risk of bacterial growth and infectionurinary incontinence due to mobility/neurologic impairmentsPsychosocial Factorsstimulation of micturition reflexprivacynormal positionsufficient timerunning wateranxiety and muscle tension = voiding is inhibitedstress triggers ADH secretion no time to pee, anxiety = no urination = higher risk of UTISociocultural Factorsdifferent traditions of urinatingFluid and Food Intakealcohol and caffeine increase urine production (ETOH inhibits ADH)food and fluids high in sodium - cause fluid retentionBeets and carotene can change urine color. MedicationsUrinary Retention (Box 1 pg 749)Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine. Antidepressant and antipsychotic agents, such as tricyclic antidepressants and MAO inhibitors. aminotryptaline (bluish tinge) Antihistamine: Pseudoephedrine (Actifed and Sudafed)Antihypertensives: hydralazine (Apresoline) and methyldopate (Aldomet)Antiparkinsonism: levadopa, trihexyphenidyl (artane), and benzotropine mesylate (Cogentin)Beta-adrenergic blockers, such as propranolol (Inderal)Opiods: hydrocodone (Vicodin) Anesthetics Peridium decreases urinary tract (turns urine orange)diuretics - medications that increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstreamsome medications alter the color of the urinepyridium (analgesic) – bright orangelevodopa (Parkinson’s)– red/brownantidepressants – blue or greenMuscle Tonegood muscle tone important to maintain stretch and contractility of bladderretention catheter for a long period = may have poor bladder muscle tonepelvic muscle tone - also contributes to storage and emptying of urinePathologic ConditionsDiseases of kidneys - affect nephrons’ ability to produce urine Abnormal amounts of protein or RBC’s in urine.kidneys may stop producing urine - renal failureHeart and circulatory disorders - heart failure, shock, HTNLost fluids due to vomiting/high fever - water is retained, urinary output fallsObstructions to urine flowKidney stonesenlarged prostateSurgical and Diagnostic Procedurescytoscopy - urethra may swellurinary tract surgery - post-op bleeding = red/pink tinged urinespinal anesthetics - decreases awareness of need to voidsurgery on structures adjacent to the urinary tract - affects voiding due to swelling of lower abdomenAltered Urine Productionmost people void 5-6 times/day14 y/o to adulthood - 1,500 mL daily urine outputPolyuriapolyuria/diuresis - the production of abnormally large amounts of urine by the kidneys, often several liters more than the usual daily outputcaused by:polydipsia - excessive thirst that results in excessive fluid intakediabetes mellitusdiabetes insipiduschronic nephritispolyuria may cause:excessive fluid lossintense thirstdehydrationweight lossOliguria and Anuriaoliguria - low urine output, usually less than 500 mL a day or 30 mL and hour for an adultcauses:abnormal fluid losseslack of fluid intakeimpaired blood flow to the kidneysimpending renal failureanuria - a lack of urine productiondialysis - a technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis to filter the blood when kidneys become unable to function adequatelytwo most common methods:hemodialysis - blood flows through vascular catheters, passes by dialysis solution in external machine and returns to patientperitoneal dialysis - dialysis solution is instilled into the abdominal cavity through a catheter, allowed to rest, then removedAltered Urinary EliminationManifestations of underlying conditions i.e. UTI:frequencynocturiaurgencydysuriaMay be a manifestation or a primary problem:enuresisincontinenceretentionneurogenic bladderFrequency and Nocturiaurinary frequency - voiding at frequent intervals, that is, more than four to six times per dayincreased fluid intakeUTI, stress, pregnancynocturia - voiding two or more times a nightexpressed in terms of number of times ex: “nocturia x 4”Urgencyurgency - the sudden, strong desire to void; may or may not be a great deal of urineaccompanies psychological stress, irritation of trigone and urethrapoor external sphincter control, unstable bladder contractionsUTIDysuriadysuria - voiding that is either painful or difficultmay accompany a stricture of the urehtraUTIinjury to bladder and urehtrajthey have to push to void, burning when voiding, like a hot poker or sunburnurinary hesitancy - a delay and difficulty in initiating voiding; often associated with dysuriahesitancy, hematuria, pyuria (pus in the urine) and frequencyEnuresisenuresis - involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4-5 y/ooften irregularaffects more boys than girlsdiurnal/daytime enuresis - may be persistent and pathologic; affects women and girls more frequentlyassociated factors:family historydifficult access to toilethome stressesUrinary Incontinenceurinary incontinence (UI) - involuntary leakage of urine or loss of bladder controlmore likely to be experienced by womenshorter urethratrauma to pelvic floor associated with childbirthmenopausal changesdirect costs:pads, diapers, laundrymedications and surgical treatmentindirect costs:increased social isolationincreased social withdrawalless positive relationships with otherspoorer perceived healthnegative effect on sexual function and intimacyincreased depressionbarrier to social interest, physical activity, other everyday activitiescauses:UTIsurethritispregnancyhypercalcemiavolume overloaddeliriumrestricted mobilitystool impactionpsychological causesassociated factors:bladder inflammation, CVA, SCI, other diseasedifficulties in independent toileting/mobility impairmentleakage when coughing, laughing, sneezingcognitive impairmentTransient (Acute)arrives suddenlylasts 6 mos or lesshas reversible causescontributing factors:polyuriaexposure to irritantsinfectionurinary retentionuse of pharmaceuticalsstool impaction/constipationatrophic urethritis/vaginitisrestricted mobility/dexteritypsychological conditions/delirium/acute confused stateEstablished (Chronic)different types, different etiologies:stressurgereflexretention with overflowfunctional incontinenceUI is NOT a normal consequence of aging, can often be treatedmajor barriers to treatmentlack of health care practitioners assessing for UIclient’s tendency not to disclose symptomsTOILETED Mnemonic: contributing factors for transient UIT: thin and dry vaginal and urethral epithelium (vaginitis/urethritis)O: obstruction (fecal impaction)I: infection (UTI)L: limited mobility (environmental barriers)E: emotional or psychological factors (depression)T: therapeutic meds (tranquilizers, diuretics, narcotics, antibiotics)E: endocrine disorders (diabetes)D: deliriumUrinary Retentionurinary retention - a condition/health symptom characterized by impaired emptying of the bladder, causing urine to accumulate and the bladder to become over distendedpoor contractility of detrusor muscle - further impairs urinationcauses:prostatic hypertrophysurgerysome medicationsassociated factors:distended bladder on palpation and percussion discomfort, restlessness, frequency, small urine volumerecent anesthesia/ surgeryperineal swellingmedicationslack of privacy or other factors inhibiting micturition may experienceoverflow voidingincontinenceelimination of 25-50 mL of urine at frequent intervalsbladder is firm, distended on palpation, displaced to one sideNeurogenic Bladderneurogenic bladder - a condition in which the client does not perceive bladder fullness and is unable to control the urinary sphincters due to impaired neurologic functionbladder may become flaccid and distended or spastic with frequent involuntary urinationNursing ManagementAssessingNursing Historydetermine:client’s normal voiding pattern and frequencyappearance of urineany recent changesany past or current urination problemspresence of an osmoticfactors influencing elimination patternPhysical Assessmentpercussion of kidneys - detect areas of tendernesspalpation and percussion of bladderinspection of urethral meatus for swelling, discharge, inflammation, if indicatedassess skin for color, texture, turgor, edemaassess skin of perineum for irritation if there is HX of incontinence, dribbling, dysuriaAssessing Urinenormal urine96% water4% solutesorganic solutes: urea, ammonia, creatinine, uric acidinorganic solutes - sodium, chloride, potassium, sulfate, magnesium, phosphorusTABLE 4: Characteristics of Normal and Abnormal UrineCHARACTERISTICNORMALABNORMALAmount in 24 hours (adult)1,200-1,500 mLUnder 1,200 mLA large amount over intakeColor, clarityStraw, amberTransparentDark amber, dark orange, red or dark brownCloudy, mucous plugs, viscid, thickOdorFaint aromaticOffensiveSterilityNo microorganismsMicroorganisms presentpH4.5-8Over 8, Under 4.5Specific gravity1.010-1.025Over 1.025, Under 1.010GlucoseNot presentPresentKetone bodies (acetone)Not presentPresentBloodNot presentOccult (microscopic)Bright redMeasuring Urinary Outputnormal urine production: 60mL/hr or 1,500 mL per dayoutput affected by:fluid intakebody fluid losses (perspiration, breathing, diarrhea)CV and renal statusbelow 30 mL/hr - low blood volume or kidney malfunctionprocedure:wear clean glovesask client to void in a collection deviceinstruct to keep urine separate from feces and no toilet paperpour into calibrated containerread amount at eye levelrecord amount on I&O sheetrinse containers and store appropriatelyhand hygienecalculate and document total output after 24 hoursprocedure for client with urinary catheter:wear clean glovestake calibrated container to bedsideplace container under collection bag, do not touchtone spout to the containeropen spout to allow urine flowclose spout and proceed as aboveMeasuring Residual Urineresidual urine - urine remaining in the bladder following voiding; normally 50-100 mLincomplete emptying of bladder due to:bladder outlet obstructionloss of bladder tonemanifestations of urine retention:frequent voiding of small amountsurinary stasisUTImeasuring residual urine:purpose - to assess amount of retained urine and determine need for interventionsmethod:catheterization after voidingbladder scan after voidingintervention:medications to promote detrusor muscle contractioninsertion of indwelling catheterDiagnostic Testsblood levels of urea and creatinine are used to evaluate renal functionblood urea nitrogen (BUN) - a measure of urea, the end product of protein metabolismcreatinine clearance - test that uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal functionDiagnosingNANDA diagnostic labels for urinary elimination:Impaired Urinary EliminationReadiness for Enhanced Urinary EliminationMore specific diagnostic labels:Functional Urinary Incontinence - inability to reach toiletOverflow Urinary Incontinence - overdistention of bladderReflex Urinary Incontinence - predictable, when a specific volume is reachedStress Urinary Incontinence - activities that increase intra-abdominal pressureUrge Urinary Incontinence - occurs soon after strong sense of urgency to voidRisk for Urge Urinary IncontinenceUrinary RetentionProblems of urinary elimination as etiology for:Risk for InfectionSituational Low Self-Esteem or Social IsolationRisk for Impaired Skin IntegrityToileting Self-Care DeficitRisk for Deficient Fluid Volume or excess Fluid VolumeDisturbed Body ImageDeficient KnowledgeRisk for Caregiver Role StrainRisk for Social IsolationPlanningExamples of overall goals:Maintain or restore a normal voiding patternRegain normal urine outputPrevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteemPerform toileting activities independently with or without assistive devicesContain urine with the appropriate device, catheter, osmotic appliance, or absorbent productPlanning for Home CareDischarge planning:assessment of client’s and family’s resources and abilities for self-care, available financial resources, need for referrals and home health servicesImplementingMaintaining Normal Urinary EliminationPromoting Fluid Intakeinc. fluid intake = inc. urine production = stimulates micturition reflexnormal daily intake: 1,500 mL for most adultsincreased fluid requirements due to:diaphoresisabnormal losses (vomiting, gastric suction, diarrhea, wound drainage)at risk for UTI or urinary calculus (need 2,000-3,000 mL fluid intake)increased intake C/I for people with:kidney failureheart failureinstead, may need fluid restriction - prevents fluid overload and edemaMaintaining Normal Voiding Habitsmedical therapy often interfere with normal voiding habitsadequate urinary elimination pattern = adhere to normal voiding habits (REVIEW Practice Guidelines: Maintaining Normal Voiding Habits)positioningrelaxationtimingfor clients confined to bedAssisting with Toiletingassistance required for clients:weakened by disease processphysically impairedassist to bathroom with call signal, encourage to use side rails by toilet ORprovide urinary equipment close to bedside and provide assistance to use themPreventing Urinary Tract InfectionsUTIs greater in women due to:shorter urethraproximity of urethra to anal and vaginal areasPrevention guidelinesdrink eight 8oz glasses of water/daypractice frequent voiding (every 2-4 hrs)avoid irritating soaps, etc. on perineal areaavoid tight-fitting clothingwear cotton underclotheswipe perineal area from front to backtake showers rather than bathsManaging Urinary IncontinenceUI - not a normal part of aging, often treatableIndependent nursing interventions for UI:behavior-oriented continence training programmeticulous skin carefor males, application of an external drainage device (condom-type catheter)stress incontinence in women - transvaginal tape sling to support urethra (local anesthesia)Continence (Bladder) TrainingRequired involvement of nurse, client, support peopleEducation of the client and support peoplebladder training - requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to voidgoals:to gradually lengthen intervals between urination to correct frequencyto stabilize the bladderto diminish urgencyfor clients who have:bladder instabilityurge incontinencevital component - inhibiting urge-to-void sensationnurse instructs client to practice deep, slow breathing until urge diminishes or disappearshabit training - timed voiding or scheduled toiling; attempts to keep clients dry by having them void at regular intervalsno attempt to motivate delay of voiding if urge occursfor:children who are experiencing urinary dysfunctionbiofeedback therapy - teaches children to relax pelvic floor to decrease wettingprompted voiding - supplements habit training by encouraging the client to try to use the toilet and reminding the client when to voidPelvic Muscle Exercises (PME)aka Kegel exerciseshelp strengthen pelvic floor musclescan reduce or eliminate episodes of incontinenceidentify perineal muscles by:stopping urination midstream ortightening anal sphincter as if to hold a bowel movementMaintaining Skin Integrityskin breakdown and ulceration due to:maceration - skin that is continually moistirritation - urine accumulation on the skin that is converted to ammoniato maintain skin integritywash perineal area with mild soap and water or no-rinse cleanser after episodes of incontinence, dry thoroughlyprovide clean, dry clothing or bed linenapply barrier ointments or creamuse of absorbent padsuse of incontinence drawsheetsApplying External Urinary Draining Devicesapplication of condom/external catheter connected to a urinary drainage system can be used for incontinent malespreferable to retention catheter because risk for UTI is minimalManaging Urinary Retentionsame as interventions to maintain a normal voiding patternif unsuccessful, PCP may order a cholinergic drug to stimulate bladder contraction and facilitate voidingclient with a flaccid bladder may use Credé’s maneuver/methodneed order from MD or NPused only for those who have lost and not expected to regain voluntary bladder controlflaccid - weak, soft, and lax (bladder muscles)Credé’s maneuver - the use of manual pressure on the bladder to promote bladder emptyingwhen all else fails:urinary catheterization until underlying cause is treated OR intermittent straight catheterization (every 3-4 hrs)Urinary Catheterizationintroduction of a catheter into the urinary bladderperformed only when absolutely necessary - risk for infection or bladder, ureters, then kidneysstrict sterile technique neededrisk for trauma to the urethracathetersmade of: rubber, plastic, latex, silicone, or PVCdiameter of lumen in French scale: larger number = larger lumenstraight catheters - inserted to drain and then immediately removedsingle lumen tube with small eye about 0.5 in from the insertion tipcoudé catheter - more rigid and has a tapered, curved tip; may be used for prostatic hypertrophyretention catheters - remain the bladder to continuously drainFoley catheter - double-lumenlarge lumen drains urinesmaller lumen used to inflate a balloon near the tip to secure it in bladderthree-way Foley - third lumen for continuous or intermittent bladder irrigationconnected to a closed gravity drainage system - preferred to prevent CAUTIcatheterdrainage tubingcollecting bagopen drainage systemseparate packagesensure sterile technique when connecting the catheter an drainage tubingREVIEW SKILL 2: Performing Urinary CatheterizationNursing Interventions for Clients with Indwelling Cathetersgoals:prevent infection of the urinary tractencourage urinary flow through the drainage systemFluidsdrink up to 3,000 mL /day if permitted for large U/Okeeps bladder flushed outdecreases likelihood of urinary stasis and infectionminimizes risk of sediment or other particles obstructing the tubingDietary Measuresacidifying urine may reduce CAUTI and calculus formationeat this: eggs, cheese, meat and poultry, whole grains, cranberries, plums, prunes, tomatoes - acidifynot this: other fruits and vegetables, legumes, milk and milk products - alkaline urinePerineal Careno special cleaning, no meatal care routine hygienic carecheck agency practiceChanging the Catheter and Tubingroutine changing not recommendedchange when there is:collection of sediment in catheter or tubingimpaired drainageRemoving Indwelling Cathetersremove after purpose has been achieved (MD order)short timelittle difficulty reestablishing normal voiding patternswelling of the urethra may initially interfereregularly assess for urinary retentionlong timemay require bladder retrainingmay be clamped and unclamped regularly (2-4 hrs) a few days before removal - check agency policyClean Intermittent Self-Catheterization (CISC)performed by clients with neurogenic bladder dysfunction (SCI)clean/medical aseptic techniquebenefits:enables client to retain independence and gain control of the bladderreduces incidence of UTIprotects upper urinary tract from refluxallows normal sexual relations w/o incontinencereduces use of aids and appliancesfrees client from embarrassing dribblingclient should havesufficient manual dexteritysufficient mental abilitymotivation and acceptance of procedurereasonable agility for women to access urethrabladder capacity greater than 100 mLbefore CISC, assess:voiding patternsvolume voidedfluid intakeresidual amountsUrinary Irrigationsirrigation - a flushing or washing-out with a specified solutioncarried out on MD orderto wash out bladderto apply a medication to bladder liningto maintain or restore patency of a catheterclosed method - preferredmay be continuous or intermittentpost-genitourinary surgery - prevents blood clots from occluding catheter3-way catheter is usedopen irrigation - risk for infection is greaterconnection between catheter and drainage tubing is brokendouble-lumen catheters - clots and mucous fragments occluding catheterSuprapubic Catheter Caresuprapubic catheter - a catheter inserted surgically through the abdominal wall above the symphysis pubis into the urinary bladdersecured with sutures or retention balloon, then attached to a closed drainage systemfor temporary bladder drainage (post-urethral, bladder, vaginal surgery)as a permanent device (urethral or pelvic trauma)nursing care:regular assessmenturinefluid intakecomfortmaintenance of patencyskin care around insertion siteperiodic clamping before removal (temporary)clamping and unclamping until satisfactory voiding (residual after voiding)sterile care of insertion site: use iodine and cover with gauze - unless site has healedsecure catheter tube to abdomenassess insertion area regularly for pubic hair, redness or dischargeUrinary Diversionssurgical rerouting of urine from kidneys to a site other than the bladderIncontinentno control over passage of urinerequires use of an external osmotic appliance to contain urinemay or may not involve a cystectomyureterostomy - when one or both of the ureters may be brought directly to the side of the abdomen to form small stomasdisadvantages:direct access for microbes from skin to kidneysdifficult to fit with an appliancemay narrow and impair urine drainagenephrostomy - diverts urine from the kidney to a stomavesicostomy - may be formed when the bladder is left intact but voiding through the urethra is not possible; the bladder wall is surgically attached to an opening in the skin below the navel, forming an incontinent stomaileal conduit/ileal loop - a segment of the ileum is removed and the intestinal ends are reattached; one end of the portion removed is closed with sutures to create a pouch and the other end is brought out through the abdominal wall to create a stoma; the ureters are implanted into the ileal pouchmost commonmost readily fitted with an appliancemucous membrane lining of ileum provides some protection from ascending infectionurine drains continuouslyContinententails creation of a mechanism that allows client to control passage of urine by:intermittent catheterization of internal reservoir: Kock pouchaka continent ileal bladder conduitnipple valves formed by portion of ilea pouchclient empties pouch by catheterization q4hstrained voiding: neobladdernew bladder from a piece of ileum - sutured to urethraNursing Care for Clients with Urinary Diversion:assessintake and outputchanges in urine color, odor, clarity (mucous shreds normal with ilea diversion)condition of stoma and surrounding skinconsult wound ostomy continence nurseidentify strategies for stoma management and peristomal problemsselecting most appropriate appliancechanging urostomy appliancesame as colostomy except:placing washcloth under stoma to collect urine when changing/measuringureteral stents in place for 10-14 daysobserve and address:body image and sexuality problemscoping with changes and managing the stomaEvaluatingif desired outcomes are not achieved, consider:client’s perception of problemclient’s understanding and compliance with health care instructionsaccess to toilet facilitiesclient’s ability to manipulate clothing, adjustments needed?appropriateness of scheduled toileting timesadequate transition lighting for nighttimemobility aids: needed? appropriate? adequate?performance of pelvic floor exercisesfluid intake, timing of fluid intakerestriction of caffeine, citrus juice, sodas, artificial sweetenersdiuretic? when taken?need continent aids like a condom cath or absorbent pads?

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