Chapter 20: Urinary Elimination .docx

 Urinary Elimination Physiology/AnatomyThe Urinary Systemeliminates waste products maintains fluid/salt balancepaired kidneys & ureters, urinary bladder & urethraalterations in urinary elimination may alter body imageidentify clients’ problems & plan appropriate nursing interventions70% of clients with incontinence have depression associated with thisKidneysRight kidney slightly higher (liver) 1200 mL or 21% of CO passes through kidney per minute. Glomerular 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 DuctUretersFunnel urine from collecting ducts into bladderAt junction between ureter and bladder:flaplike fold of mucous membrane (valve-effect) to prevent reflux of urine. BladderWomen: 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)allows bladder to expand and contractouter serous layerCapacity: 300mL to 600mL Urethra (4cm females; 8cm males) mucous membrane is continuous with bladder and uretersinfection in urethra easily spread up UT. Pelvic floorinternal sphincter = involuntary controlexternal sphincter = voluntary controlUrination Micturition, voiding, and urination all refer to the process of emptying the bladder. urine collects in the bladder until special nerve stimulation of stretch receptors on bladder wall. usually occurs between 250mL- 450mL of urine. (50-200mL for children) stretch receptor impulses sent through spinal cord to voiding reflex center at S1-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. ICH or spinal cord injury = involuntary urinationOlder adults w/ impaired cognition = unawareness of need to urinate or unable to respond to urge of urination. Factors Affecting VoidingDevelopmental FactorsInfants: 250-500mL, 20x a day, sp.gr: 1.008. colorless and odorless. School-age children (5-10yr): kidneys double in size -> urination 6-8x a day. Enuresis: involuntary urination when control should be established.Nocturnal enuresis: bed-wetting Older Adultsprerenal failure: hypertensionIntrarenal failure = hypertension, diabetes, toxinsPost renal failure = outflow obstructiondiminished excretory function factors that impair renal function:arteriosclerosissurgerymore susceptible to toxicity from medications due to decreased excretionUrinary 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. Psychosocial Factorsstress triggers ADH secretion no time to pee, anxiety = no urination = higher risk of UTISociocultural factorsdifferent traditions of urinating Fluid and Food Intake (1.5-3L of fluid)alcohol and caffeine increase urine production (ETOH inhibits ADH)Beets 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 (blueish 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)Muscle Tonegood muscle tone important to maintain stretch and contractility of bladder. Pathologic ConditionsDiseases of nephronsAbnormals amounts of protein or RBC’s in urine.Heart and circulatory disorders. Kidney stonesenlarged prostateSurgical and Diagnostic Procedures Altered Urine Production/ EliminationPolyuriaincrease fluid intakeDiuretics, lots of ETOHPresence of thirst, dehydration, and weight loss. History of diabetes or kidney disease. some stages of renal failureOliguria, anuria (<500mL in 24 hr)Decreased fluid intakedehydrationhypotension, shock, or heart failurehistory of kidney disease or renal failure or decrease perfusion to kidneys (high BUN, creatinine, edema, hypertension) Frequency of nocturia (2 or 3 times a night)pregnancyincreased fluid intakeUTIUrgency - sudden desire to urinate immediately stressUTIenlarged prostateDysuria - pain or difficultyUTIhematuria, pyuria (pus in urine)Enuresis - involuntary urination of childrenfamily historydifficult access to toilet facilitiesstress Incontinence - involuntary urination of adultsbladder inflammation or CVAdifficult access to toilet (impaired mobility)leakage when coughing, laughing, sneezing cognitive impairmentSCIRetention distended bladder on palpation and percussion discomfort, restlessness, frequency, small urine volumerecent anesthesia/ surgeryperineal swellingmedicationslack of privacy or other factors inhibiting micturition Neurogenic Bladderimpaired neurologic function (SCI) does not perceive fullness therefore unable to control urinary sphinctersself-catheterization (q4h) Urinary DiversionsContinent (indicated by bladder cancer) Kock Pouch (new bladder out of ileum) Neobladder (intact urethra) IncontinentSuprapubic catheter (urethral trauma, short-term 2-3 weeks) UreterostomyNephrostomyVesicostomy(urethra no longer functioning, bladder attached directly to skin)Ileal conduit (ileum used as collection bladder)Nursing ProcessAssessmentNursing historyfrequency signs/symptoms Factors that affect urination any changes in urinationPhysical assessment ureteric frost (snowflake crystals) urethral meatus Characteristics of urine (color, clarity, and odor) I/OHydration statusExamination of urineRelate data from diagnostic tests & proceduresBUN/ creatinine GFR Urine Tests & Diagnostic ExaminationsUrinalysisCulture Bladder scanultrasound BUN & CreatinineCharacteristics of Normal and Abnormal Urine (Table 4 pg 754)CharacteristicNormalAbnormalNursing ConsiderationsAmount1200mL-1500mLunder 1200 mL or a large amount over intake should be equal.<30mL/hr may indicate decrease blood flow to the kidneys, should be reported A.S.A.PColor, clarityamber, transparentdark amber, cloudy, dark orange, red or dark brown, mucous plugs, thickSome food and drugs can color urine.Menstrual bleeding should not be confused with hematuria. WBC, infections, prostatic fluid may cause cloudy urine, Odorfaint aromaticoffensivesome foods (asparagus) cause musty odor; infections can have a fetid odor, high urine glucose smells sweetSterilityno microorganisms presentmicroorganisms presentbladder is sterile, contamination may occur from perineum during collectionpH4.5-8<4.5, >8alkaline = alkalosis, UTI or diet high in fruits and veggiesacidic = starvation, diarrhea, high protein food or cranberriesSpecific gravity1.010-1.025<1.010, >1.025concentrated = higher, dilute = lowerGlucosenot presentpresentindicates high blood glucose levelsKetone bodies (acetone)not presentpresentend product of fatty acid catabolism, may be present in uncontrolled DM, starvation, excessive ingestion of aspirinBloodnot presentpresentUTI, kidney disease, UT bleedingDiagnosingNANDA nursing diagnoses:Functional Urinary Incontinencenormally continent person unable to reach toilet in time Overflow Urinary Incontinenceinvoluntary loss due to overdistention of bladderReflex Urinary Incontinenceloss of urine at predictable intervals when specific bladder volume is reachedStress Urinary Incontinencesudden leakage due to increased intra-abdominal pressure. Urge Urinary Incontinenceinvoluntary passage after urge to voidRisk for Urge Urinary Incontinence Urinary RetentionNANDA Diagnoses w/ etiology Disturbed body imageUrinary incontinencePainRisk for infectionToileting self care deficitImpaired urinary eliminationPlanningSample goals:maintain or restore normal voiding patternregain normal urine outputprevent associated risks (infection, imbalance, skin breakdown etc.)perform voiding independently w/ or w/o assistive devicesContain urine with appropriate deviceMake sure goals are:realistic & individualizedestablished with the clientOutcome measures: ex. no bladder distention, void of 300ml or > will perform Kegel exercises BIDCollaborative careImplementingClient educationContinence (bladder) trainingclient resists urge or sensation to urinate and only void according to a timetable to gradually stabilize the bladder and diminish urgency. also provides larger voided volumes and longer intervals between voiding. Habit trainingscheduled toileting, have client void at regular intervalsno delay voiding of urge occursused in children with urinary dysfunctionPrompted voidingprompting or reminding client when to void.Pelvic Muscle ExercisesMaintaining Skin Integrity Maintain elimination habitsmedications usually interfere with normal voiding habitsassist client to maintain habits (assisting with toilet PRN) Fluid intake (2-3L/day) promote increased fluid intake -> increased urine production -> more stimulation of micturition reflex. keep bladder flushed out and decreases risk of sediment or other obstructions1500 mL of measurable fluid is adequate for most adultsmay be c/i for clients with kidney or heart failure. Prevent infectionsDrink 8 glasses of water a dayPractice frequent voidingAvoid harsh cleansing products.Avoid tight-fitting pantsWear cotton rather than nylon (enhances ventilation)Wipe from front to backtake showers rather than baths (bacteria in bath water) Acidifying urineFoods such as:eggs, cheese, meat, whole grains, cranberries, plums, and tomatoes increase the acidity of urine. acidifying the urine of clients reduce risk of UTI and calculus formation. MedicationsCatheter & skin careHazards:infectiontrauma Types of catheters:plastic catheters (1 week or less): less flexiblerubber or Silastic catheters (2-3 weeks) Silicone catheters (2-3 months): create less encrustation to meatus, but expensive.PVC catheters (4-6weeks): soften at body temperature and conform to the urethra. Lengths of catheters:Female: 22cmMale: 40 cmSize of catheters:#8-10: children#14-16: adults#18: some menBalloon size Adults: 5mLChildren: 3mL Condom cathetersIndications for FoleyAcute urinary retention or bladder outlet obstructionNeed for accurate output in critically ill clientsPeri-operative use for selected surgical proceduresTo assist in healing of open sacral or perineal wounds in incontinent clientsClient requires prolonged immobilization To improve comfort for end of life care Foley CareCare:Urinary catheters is indicatedHand hygieneMust be continuously connected to the drainage bagNO breach in systemRoutine daily meatal hygiene & after BMUrinary catheter bag should be emptied regularly into a clean containerSecurement deviceNo dependent loops ................
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