Chapter 46: Urinary Elimination Flashcards
Urinary elimination depends on the function of what organs?
kidneys, ureters, bladder and urethra
What nerves must be present for urinary elimination to occur?
efferent (motor) and afferent (sensory) nerves from the bladder to the spinal cord and brain
When the urinary system fails to function, eventually
all organ systems are affected
Approximately ________ of the cardiac output circulates through the kidneys each minute.
20-25%
Nephron
functional unit of the kidney that forms urine
glomerulus
filters approximately 125 ml of filtrate per minute
Not all of the filtrate is excreted as urine:
approximately 99% is resorbed into the plasma leaving 1% excreted as urine
Normal urine output in an adult per day
1000-2000 ml/day
an output of less than 30 m/hr indicates what?
possible circulatory, blood volume or renal alterations
The kidneys are responsible for maintaining a normal RBC by producing
erythropoietin
Erythropoietin
functions within the bone marrow to stimulate RBC production, maturation and prolongs the life of mature RBC’s
Patient with chronic kidney conditions cannot produce
sufficient quantities of erythropoietin therefore are prone to anemia
Aldosterone is secreted from
the adrenal cortex
Aldosterone causes
retention of water -> increases blood volume -> increases arterial blood pressure -> increases renal blood flow
Why are patients with chronic renal failure prone to developing renal bone disease?
they do not make a sufficient amount of active vitamin D
Renal bone disease results in
demineralization of bone caused by impaired calcium absorption
ureters
tubular structures that enter the urinary bladder from the kidneys
ureters enter the bladder from the
posterior wall
What causes urine to enter the bladder in spurts?
peristaltic waves
A kidney stone (renal calculus) within the ureter results in
strong peristaltic waves that attempt to move the stone into the bladder resulting in renal colic (causes intense flank pain)
The urinary bladder
hollow, distensible, muscular organ that stores and secretes urine.
The urinary bladder lies where?
in the pelvic cavity behind the pubic symphysis
Urethra
exits the bladder and passes out of the body
The urethra is lined with
mucous membranes
Glands of the urethra
secrete mucus into the urethral canal
In a woman, the urethra is how long?
1.5-2” long
In men, the urethra is approximately how long?
8” long
Most people feel the need to void from
400-600 ml/urine
As the bladder stretches,
sensory impulses are sent to the micturition center in the sacral spinal cord.
What makes urination a voluntary process?
the fact that impulses can be ignored or acted upon
Damage to the spinal cord above the sacral region causes
reflex incontinence.
however, the micturition reflex pathway may remain in tact.
reflex incontinence
loss of voluntary control to urinate.
Overflow incontinence
occurs when the bladder is overly full and the pressure in the bladder exceeds the sphincter pressure.
involuntary loss of urine results
Causes of overflow incontinence include:
head injury, spinal cord injury, diabetes and trauma to the urinary system
Factors influencing urination
- urinary retention
- urinary tract infections
- catheter associated urinary tract infections
- urinary incontinence
- urinary diversions
Urinary incontinence
T. 46-1 p 1104-5’
involuntary leakage of urine that is sufficient to be a problem
Urinary Retention can be caused by
post void residual
BPH
Types of UTI’s
bacteriuria
pyelonephritis
dysuria
cystitis
Urinary diversions include
ureterostomy
nephrostomy
Diabetes Mellitus and neuromuscular diseases cause
changes in nerve functions
Diabetes mellitus and neuromuscular diseases causes changes in nerve functions that can lead to
reduced bladder tone
reduced sensation of bladder fullness
inability to inhibit bladder contractions
End Stage Renal disease
irreversible damage to the kidney tissue marked by fluid and electrolyte imbalances, accumulation of wastes in the blood and systemic symptoms of N/V, headache, coma and convulsions
Urinary retention
accumulation of urine due to the inability of the bladder to empty
With severe retention, the bladder can hold as much as
2000-3000 ml of urine
When assessing for bladder distention in a patient with urinary retention, it may be
extremely painful
Residual Urine (post void residual)
inability to empty the bladder after voiding
- straight cath or bladder scanner to dx
- breeding ground for microorganisms
UTI’s
most common health care acquired infection
80% of UTI’s result from
the use of indwelling catheters (results in over 1 million UTI’s each year in US)
Each day a catheter is in place, there is a
5% increase in bacteria in the urine
Catheter associated UTI’s are associated with
Increased hospitalizations
Increased morbidity and mortality
Longer hospital stays
Increased hospital costs
For UTIs, what is the most common pathogen?
the patient’s own colonic flora including Escherichia coli (E coli)
What causes UTIs in women?
poor hand hygiene
not wiping from front to back
frequent sexual intercourse (not voiding directly after)
Benign Prostatic Hyperplasia
in men makes them prone to urinary retention
Dysuria
symptoms of a lower UTI
What are symptoms of dysuria?
Burning during urination as urine passes over inflamed tissues
As the infection worsens (pyelonephritis), fever, chills, nausea, vomiting, and malaise develop
Cystitis
infection of the bladder
Cystitis can cause
Frequent sensation to void (frequency)
Concentrated urine and cloudy urine due to WBCs in urine
Hematuria
blood in the urine due to irritation to the bladder and urethral mucosa
Pyelonephritis
kidney infection
Pyelonephritis symptoms
flank pain, tenderness, fever and chills
Stress incontinence
sneeze, cough
Urge incontinence
can’t get to the bathroom in time
Over Active Bladder
results form sudden, involuntary contraction of the muscles of the urinary bladder resulting in the urge to urinate
Common causes of an over active bladder are
diabetes, CVA, UTI, and anxiety (like test anxiety)
Incontinence can lead to
impaired body image and loss of independence
psychological reasons for sexual dysfunction
Continued incontinence poses a risk for
pressure ulcers and skin breakdown
Consider environmental barriers that are risk for incontinence and falls including
Patients with restricted mobility
Chairs that are too low for older adults to get out of
Beds raised in the high position
Difficulty undoing buttons and zippers
Urinary Diversion
temporary or permanent bypass from the bladder and urethra as the exit route for urine
Urinary Diversion requires
a stoma (artificial opening) on the abdomen to drain the urine
Urinary Diversion is used in patients who
have cancer, radiation or constant urinary tract infections
Nephrostomy
catheter inserted directly into the renal pelvis
Psychosocial implications of Urination
- self concept: body image, self-esteem, roles and identity
- culture: very private event, embarrassing
- sexuality
Incontinence is NOT
NOT a normal part of aging
Noninvasive alternatives to catheterization includes
Voiding schedule
Use ultrasound to assess urinary retention as opposed to straight catheterization
Use standards of care
Collaboration with specialists
When assessing a patient, assess for
Skin and mucosal membranes: urethral meatus
Bladder for distention
Skin turgor
Oral mucosa (gather data about hydration)
Lab values for kidney function and electrolyte imbalances
Women with vaginal infections often have associated UTIs
Assess the quality of the urine
Measure I&O
When measuring I&O’s, report
- extreme increases or decreases in urine volume.
- an hourly output of <30ml/hr for 2 consecutive hours is cause for concern
What are factors that influences urination?
Age Environmental Factors: Medication History: Psychological Factors: Muscle Tone: Fluid Balance: Current Surgical or Diagnostic Procedures: Presence of Disease Conditions:
Nocturia
awakening to void one or more times a night
Polyuria
excessive output of urine
Oliguria
decreased output despite normal intake
Oliguria may be due to
increased loss from vomiting, diarrhea or perspiration OR kidney disease
Anuria
no urine is produced. kidney disease
Diuresis
promotion of increased urination through means such as caffeine, alcohol (inhibits ADH), or the body’s compensatory systems (3-4th day post operative, for example).
Characteristics of urine
color, clarity, odor
Color of urine
Pale straw color to amber.
Document any abnormal color and/or sediment esp. if the cause is unknown
Clarity of urine
urine should be transparent (see through)
Document cloudy or foamy (high protein concentration) urine-may be a result of WBCs and bacteria
Odor of urine
Document any odor that is not characteristic.
Sweet/fruity
Ammonia smell
Certain medications and foods can also cause a distinctive odor (asparagus, amoxicillin)
Strong ammonia odors of urine are usually from
stagnant urine-incontinence.
Sweet/fruity of urine is usually occurs from
acetone as a byproduct of incomplete fat metabolism (starvation, diabetes)
Common Urine Tests
urinalysis, specific gravity, and urine culture
urinalysis
clean catch or catheterized
specific gravity
the weight or degree of concentration of a substance compared with an equal volume of water.
urine culture
sterile or clean voided sample
sent to the laboratory to determine which specific antibiotics are effective (sensitivity)
Common Diagnostic Urine Tests
- Radiographs (KUB, plain film)
- Intravenous Pyelogram (IVP)
- Ultrasound
- Invasive Procedures
- Endoscopy
- Cystoscopy
Many medications directly or indirectly contribute to
urinary dysfunction leading to urinary retention or incontinence
Meds that directly or indirectly contribute to urinary dysfunction
Antipsychotics Antidepressants Alpha adrenergic agonists (clonidine) Calcium channel blockers (Cardizem, Norvasc, verapamil) Sedative hypnotics Opioid analgesics ACE inhibitors (captopril, Vasotec, Altace) Antihistamines (Benadryl)
Factors Related to Aging
Prostate Enlargement in men
Changes in the urethral mucosa associated with the loss of estrogen susceptibility to UTIs
The ability of the kidney to concentrate urine declines
Nocturia
Urinary Frequency: decreased bladder capacity causing more frequent urination
Possible muscle wasting due to immobility
Muscle damage due to childbirth
Being overweight
Over consumption of caffeine or alcohol
Nursing Diagnosis
Functional Urinary Incontinence Stress Urinary Incontinence Urge Urinary Incontinence Risk For Infection Toileting Self-care Deficit
Example of short term goals for urination
After surgery the patient should have normal voiding with complete bladder emptying within 24 hours
Example of long term goals for urination
The patient with stress incontinence may need weeks of pelvic floor (Kegel) exercises.
Possible interventions
- teach self-care/hygiene activities
- place the patient in normal positions of urination if possible
- using the sound of running water to promote relaxation to help the patient void
- maintain measures to prevent infection
- keep environment safe
- understand side effects of patient medications
Teaching self-care/hygiene activities include
Increasing/maintaining an adequate fluid intake (2200-2700ml/day)
Include fluids high in acid such as cranberry or apple juice
Hand hygiene
The normal sterility of the urinary tract
Proper perineal care esp. after urination and defecation
What are normal position of urination for men and women?
men: standing
women: sitting up right
keeping the environment safe
make a clear path to the bathroom and call light in reach to avoid falls
Understanding the side effects of your patient medications includes checking if they cause
constipation, dry mouth, skin irritation and urinary retention
A ___________________ is not best practice for incontinence.
indwelling catheter (foley catheter)
Proper care and handling of a patient with a foley catheter includes
- keeping bag below the level of patients waist
- keeping the tubing free from kinks and “dependent loops”
- perform perineal care and catheter care at least 3 times a day AND as needed
- use institutions securement devices (Stat-loc) to prevent the catheter tubing from sliding in and out of the urethral meatus
- encourage adequate fluid intake to prevent stagnation of urine in the bladder and keeps the catheter tubing free from sediment
- maintain a closed urinary drainage system
Removal of an indwelling catheter
assess the patient’s urinary function:
note the first voiding
keep an accurate I&O for 24
You should assess for bladder distension in a patient that has an indwelling catheter if
4 hours have elapsed without voiding OR if the patient is experiencing discomfort
If patient is unable to void, the nurse should
- use an ultrasound if available
- it may be necessary to either straight cath the patient or even replace the foley catheter if the patient is unable to void
Bladder Training includes
- Kegel Exercises
- initiating a toileting schedule
- avoid an overfilled bladder which increases the risk of incontinence
- minimizing caffeine and alcohol
- take a prescribed diuretic med early in the morning
- maintain a healthy weight
Kegel Exercises
pelvic floor exercises
Evaluate compliance with
- dietary restrictions
- pelvic muscle exercises
- effectiveness of antibiotic treatment
Add tables from slide
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