Exam 2 module 4 part 3 - Urine Flashcards
Chapter 25 Urine elimination
infant urine output
o Normal specific gravity for a newborn: 1.008.
o Urine becomes more concentrated over time.
o Well-hydrated infants produce 8 to 10 wet diapers per day.
o No voluntary control of urination due to immature neuromuscular function.
18-36 mo. old
- Toilet Training (18-36 months): Requires:
o Control of external urethral sphincter
o Ability to sense the urge to void
o Skills to communicate needs and remove clothing
o Occasional involuntary urination (e.g., during play) is normal.
- Enuresis (Involuntary Urination)
o Daytime enuresis is normal in young children.
o Nocturnal enuresis (bedwetting): Common in children aged 6-7 years.
o Causes:
Insufficient ADH (antidiuretic hormone)
Bladder pressure
Urinary infections
Emotional stress
o Management Tips:
Use bed alarms to wake the child when wetting occurs.
Limit fluid intake in the evening.
Reassure parents that most cases resolve naturally.
Medical evaluation is advised if bedwetting persists into school-age years.
B. Developmental Factors: Older Adults
- Kidney Changes with Aging:
o Kidney function declines after age 60, with only about two-thirds of nephrons remaining by age 75.
o Reduced ability to dilute or concentrate urine, increasing risk during illnesses (e.g., diarrhea, vomiting).
o Arteriosclerosis (blood vessel hardening) reduces renal blood flow, impairing waste filtration.
o Increased risk of drug toxicity due to slower excretion. - Other Age-Related Physiological Changes:
o Bladder changes: Loss of elasticity and muscle tone, leading to:
Urinary retention
Incomplete emptying → Increased risk of bladder infections
o In Females: Loss of abdominal and perineal muscle tone (due to childbearing) → Higher risk of incontinence.
o In Males: Prostate enlargement (benign prostatic hyperplasia - BPH) → Difficulty in urination and risk of urinary retention. - Symptoms Due to Aging:
o Nocturnal frequency: Increased nighttime urination.
o Bladder infections: Result from incomplete emptying.
o Urinary leakage: Especially with weakened pelvic muscles.
o In males:
Dribbling and reduced urine stream force.
Difficulty starting urination.
o Urine retention: Risk of infection from residual urine
adult urine output
- Normal urine production: ~ 1,500 mL/day or 50–60 mL/hour.
o Daily output may range from 1,000 to 2,000 mL, depending on fluid intake and losses.
* Voiding Frequency:
o Most people void about 5 to 6 times per day, typically:
After awakening
After each meal
Before bedtime
Pale to clear urine generally signifies adequate hydration.
Thiazide diuretics
Reduce sodium and water retention and dilate blood vessels, lowering blood pressure.
incidated for Hypertension, edema
K sparing di
Potassium-Sparing Diuretics Reduce water retention without causing potassium loss.
Heart failure, cirrhosis
Loop di
Loop-Acting Diuretics Prevent water reabsorption in the kidneys, producing large volumes of urine. Severe edema, heart failure
rx interactions di
- Digoxin: Risk of toxicity due to potassium imbalance (especially with loop or thiazide diuretics).
- Antihypertensives: Potentiates blood pressure-lowering effects.
- Lithium: Risk of lithium toxicity with sodium depletion.
- Antidepressants & Cyclosporine: Increased risk of potassium imbalance (with potassium-sparing diuretics).
SE di
- General: Weakness, muscle cramps, joint pain.
- Thiazides: Increased sensitivity to sunlight, dizziness, and skin rashes.
- Loop Diuretics: Risk of electrolyte imbalances and hypokalemia (low potassium).
other Rx classes
- Muscarinic Receptor Antagonists Block nerve signals to the bladder muscle, reducing frequent urination. Urge incontinence
- anticholinergics ‘increase bladder cap’
- antidepressants relax detrusor and stim sphinct for stress incontinence
- Estrogen Therapy Improves blood flow and thickens urethral tissues. Postmenopausal incontinence
- Spinal cord and MS uses botox inject for OAB
- Pyridium is azo
my drugs are for urge incontinence except i have a tight PF so no incont
Do you need an indwelling cath after a urinary surgery
yes. common for hysterectomy, transurethral resect prostate
do you need an indwelling cath if you have a pelvic surgery
yes.
it helps with drainage because theres incr. pressure inside the pelvis
Effects of Anesthesia on Urinary Function
- General Anesthesia:
o Lowers blood pressure and reduces glomerular filtration rate (GFR) → Decreased urine formation. - Spinal Anesthesia:
o Blocks nerve signals to the bladder, reducing awareness of the need to void → Risk of bladder distention.
Nephrotoxic Rx
- Antibiotics: e.g., Gentamicin, Amphotericin B (especially with prolonged use).
- NSAIDs: e.g., Aspirin, Ibuprofen (in high doses or long-term use).
nsaid because it increases the prostagladins locally to the effert arteriole which reduces kidney filtration
Problem with diagnostic procedures
- Diagnostic procedures (e.g., cystoscopy, catheterization) can introduce bacteria, increasing the risk of urinary tract infections (UTIs) and retention.
Heart failure, diabetes, or shock → Low urine output (oliguria) or no urine output (anuria).
keep in mind that blood flow to the kidneys will impact GFR
Neurogenic bladder
- Neurogenic Bladder: Caused by nerve damage from conditions such as:
o Stroke
o Spinal cord injuries
o Multiple sclerosis (MS) - Symptoms: Loss of bladder control, resulting in:
o Flaccid bladder: Weak and unable to contract → Urine retention.
o Spastic bladder: Involuntary contractions → Frequent urination or incontinence.
retain or freqent, it can go either way
you jump into a swimming pool and then you become the swimming pool
or you jump in and then all the waters gone
Sepsis
The kidneys are assholes, they protect their own output at the expense of the rest of the body
- Cause the kidneys to retain water due to the body’s immune response.
- High fever often triggers the kidneys to reabsorb more water, reducing urine output.
Immobility, cognitive, Communication Impairments:
- Conditions such as Alzheimer’s disease or severe psychiatric disorders can impair the ability to:
o Perceive the urge to void.
o Manage self-care for toileting.
o Result in functional incontinence = the problem lies in getting to the toilet and not the bladder itself - Immobility: Increases the risk of urinary stasis, leading to infections and calculi formation.
How to keep away UTI
Preventing Urinary Tract Infections (UTIs): Key Patient Education
* Hydration: Drink 8–10 glasses (64–80 oz) of water daily.
* Frequent Voiding: Urinate often, and after sexual activity.
* Hygiene:
o Wear cotton underwear and loose-fitting clothing.
o Wipe front to back to prevent bacterial entry.
* Avoid Irritants: Such as spermicidal products, bubble baths, or baking soda baths.
labs
o Blood Urea Nitrogen (BUN): Indicates kidney function.
Increased: In renal failure, dehydration, or high protein intake.
Decreased: In malnutrition or liver disease.
o Creatinine: Measures kidney efficiency in filtering waste.
Increased: In kidney disease or obstruction.
Cr and BUN high mean its a kidney problem
Normal Urine properties
- Color: Pale yellow to amber (varies with hydration).
- Clarity: Clear (cloudiness may indicate infection or crystals).
- Odor: Mild (strong or foul odor suggests infection or dehydration).
- Output: Typically 50–60 mL/hour or 1,500 mL/day.
I & O and what is normal
- Measuring and Interpreting Intake and Output (I&O):
* Fluid Intake Includes: Oral fluids, IV fluids, tube feedings, and irrigations.
* Output Includes: Urine, vomitus, wound drainage, and liquid stools.
* Normal Urine Production: 50–60 mL/hour or 1,500 mL/day.
Urine High output + Normal intake
possible DI (insip)
or on diuretics
Technique for CVA
Assessment:
* Technique: Percuss at the costovertebral (CV) angle (between the 12th rib and spine).
CVAT + = pyelonephritis or inflammation
What is a distended bladder
On inspection, some swelling, rising over pubis symphisis. Firm and tender on palpation. Percussion reveals dull sound on a full bladder.
tympanic sound is air filled structures
Perineal skin check - why?
o Watch for skin breakdown or excoriation from prolonged urine contact.
o High risk in patients with urinary catheters or incontinence.
o Both urine and stool on the skin → Rapid breakdown and infection risk.
while down there check the urethra for erythema, discharge, swelling, odor for any possible infections
monitor what labs in elderly (75+ especially)
Monitor BUN, creatinine, and GFR.
population is also increased risk for incontinence, retention, and UTIs.
Cystoscopy definition, prep, post
A. Cystoscopy:
* Purpose: Directly visualize the urethra, bladder, and ureteral orifices using a cystoscope. May also be used for biopsies or treating abnormalities.
Preparation:
* Consent: Ensure a signed consent form is obtained.
* Anesthesia: The procedure is done under general, spinal, or local anesthesia.
o General anesthesia: NPO (no food or fluids) for 8 hours prior.
o Local anesthesia: Clear liquids only for 8 hours prior.
Postprocedure Care:
* Hydration: Encourage increased fluid intake to flush out the urinary tract.
* Monitoring: Check vital signs and I&O (intake and output).
* Allergic Reactions: Watch for signs of reaction to contrast media (e.g., rash, nausea, hives).
Ultrasound renal/bladder def,prep,post
B. Ultrasound (Renal or Bladder):
* Purpose: Produces images of the kidneys, ureters, and bladder using high-frequency sound waves.
o Commonly used for detecting kidney stones, cysts, or tumors.
Preparation:
* Consent: Ensure a signed consent form is obtained.
* Bladder Ultrasound: The patient may need to drink 1 liter of fluid 90 minutes before to ensure a full bladder.
* No dietary restrictions for a renal ultrasound.
Postprocedure Care:
* Special Care: None required. Routine care is sufficient.
CT
- Purpose: Uses X-rays and contrast media to produce a 3D image of the urinary tract. Helpful for diagnosing kidney stones, tumors, or trauma.
Preparation: - Consent: Ensure a signed consent form is obtained.
- Dietary Restrictions: NPO (no food or fluids) for 2 to 4 hours prior.
- Remove Metal Objects: Ask the patient to remove jewelry, eyeglasses, or metal objects.
Postprocedure Care: - Monitoring: Check vital signs and I&O.
- Allergic Reactions: Watch for reactions to the contrast media (e.g., rash, nausea, hives).
Renal Biopsy
. Renal Biopsy:
* Purpose: Removes a small piece of kidney tissue for microscopic examination to diagnose conditions such as glomerulonephritis, tumors, or nephrotic syndrome.
o Typically performed under ultrasound guidance.
Preparation:
* Consent: Obtain a signed consent form.
* Allergy Check: Confirm the patient has no allergies to shellfish or iodinated dye, as contrast may be used.
* NPO:
o 6–8 hours prior for an open biopsy.
o 4 hours prior for a needle biopsy.
* Baseline Tests: Ensure coagulation studies (PT, INR, aPTT) and hemoglobin results are available.
Postprocedure Care:
* Bedrest: Maintain bedrest for 6 to 24 hours as ordered.
* Bleeding: Monitor the biopsy site for bleeding.
* Urine Assessment: Check for blood in urine (hematuria).
* Vital Signs and I&O: Monitor closely.
* Report: Flank pain, chills, or difficulty urinating immediately.
Cystometry (Urodynamic Testing):
- Purpose: Measures bladder pressure and capacity, identifying nerve or muscle issues causing urinary problems. A catheter and pressure probe are inserted, and the bladder is filled with warm fluid or contrast.
Preparation: - Consent: Obtain a signed consent form.
- No dietary restrictions.
- Patient Instructions: Explain the importance of cooperating with positioning and activities during the test.
Postprocedure Care: - Hydration: Encourage increased fluid intake.
- Monitoring: Observe for:
o Vital sign changes
o I&O
o Report pain, chills, or difficulty urinating.
Intravenous or Retrograde Pyelogram
Indirect visualization
A. Intravenous Pyelogram (IVP):
* Purpose: Uses IV contrast medium to visualize the kidneys, ureters, bladder, and renal pelvis. Measures renal function based on contrast flow.
B. Retrograde Pyelogram:
* Purpose: Visualizes the renal collecting system using contrast injected via a catheter inserted through a cystoscope. Commonly used when IVP cannot be performed due to renal insufficiency.
Preparation for IVP/Retrograde Pyelogram:
* Consent: Obtain a signed consent form.
* Baseline Tests:
o Ensure BUN and creatinine results are available (contraindicated in renal failure).
* Dietary Restrictions: NPO for 8 hours prior.
* Medications:
o Adjust insulin doses for diabetic patients.
o Hold medications such as anticoagulants (aspirin, heparin) if ordered.
* GI Preparation: Some patients may need a laxative the night before to clear the intestines for better visualization.
* Pregnancy Check: Confirm the patient is not pregnant or breastfeeding.
* Medication History: Ask if the patient has taken bismuth-containing medications (e.g., Pepto-Bismol) or had a recent barium study, as these can affect test results.
Postprocedure Care:
* Hydration: Encourage increased fluid intake to flush out contrast.
* Monitoring:
o Vital signs and I&O
o Look for rash, nausea, or hives (allergic reaction to contrast).
What counts as input
- Oral fluids (water, juice, coffee)
- Semiliquid foods (soup, gelatin)
- IV fluids (including continuous infusions)
- Tube feedings
- Irrigations (if not withdrawn)
What counts as output
- Urine
- Emesis (vomit)
- Diarrheal stools
- Wound drainage (from suction devices or surgical drains)
- NG tube drainage
What to keep in mind when measuring I & O
- keep a sign on the room or mark the chart
- aseptic technique w/ urine samples
- always gloves
- EVERY HOUR IN ICU
- Every 24 hours and every shift in general care
PT INR
the time it takes to coagulate
1st line for kidney eval imaging study
US
imaging study pref for detecting stones and tumors
CT
Anuria
less than 100 mL in 24 hours
can be common in CHF and kidney fail
Oliguria
less than 400 in 24 hours but more than 100 mL
Acute renal failure
Sudden rise in serum creatinine by 25% or more. Causes include: low blood flow, kidney injury, or urinary obstruction.
End stage renal disease
Chronic renal failure requiring dialysis or transplantation. Associated with high creatinine levels.
Enuresis
Involuntary loss of urine, commonly seen in children (bed-wetting).
Micturition
The act of urinating
Pessary
A device inserted into the vagina to support organs and reduce bladder pressure, often used in stress incontinence.
Tea color urine
liver disease
vasculitis
Cloudy urine could indicate…
Crystals
Frothy urine
Proteinuria
Ammonia smell
UTI
Garlic or onion smell
caused by eating the food
Acidic urine
high protein diet
cranbery juice
uncontrolled diabetes
alkaline urine
UTI
veggie diet
citrus
proteinuria
Indicates renal disease like glomerulonephritis or diabetic nephropathy
Why might ketones be in the urine besides DKA
fasting or high protein diet
Hemoglobin in urine
bleeding
Bilirubin in urine
Liver disease
Bile duct obstruction
Urobilinogen
Liver disease if increased
Nitrites
bacteriuria
Leukocyte esterase
UTI or bladder inflammation
Microscopic examination of urine
Renal cells, Transitional cells, squamous cells, casts or crystals, bacteria/yeast/parasites
Renal cells found on microscopic exam
Indicates kidney tubule damage (e.g., glomerulonephritis).
Transitional cells found on microscopic exam
Indicates urinary tract damage (e.g., trauma, cancer).
Squamous cells found on microscopic exam
Large numbers may indicate contamination from the external genitalia.
in rare circumstances it can be a normal finding
Casts found on microscopic exam
Hyaline = dehydration
Granular = renal disease, viral disease
RBC = glomerulonephritis
Crystals found on microscopic exam
Oxalate = kidney stones
Uric acid = gout or chemotherapy
What is a refractometer used for
A more precise specific gravity
Name primary diagnoses in urinary
- Impaired Urinary Elimination: Inability to properly eliminate urine.
- Urinary Incontinence: Types include:
o Functional: Barriers (e.g., mobility issues) prevent reaching the toilet.
o Overflow: Bladder overfills, causing leakage.
o Reflex: Involuntary loss without awareness, common in spinal cord injuries.
o Stress: Leakage with increased abdominal pressure (e.g., coughing, sneezing).
o Urge: Sudden, strong need to urinate with involuntary leakage.
Secondary diagnoses
- Anxiety: Related to urinary urgency or incontinence episodes.
- Acute Pain: Related to bladder spasms or UTI.
- Social Isolation: Due to embarrassment from incontinence.
- Risk for Fluid Volume Deficit: From excessive urination (e.g., polyuria).
NIC interventions
- Bladder Irrigation: To prevent or relieve obstructions.
- Environmental Management: Provide appropriate lighting and remove obstacles to the bathroom.
- Fluid Monitoring: Track intake and output (I&O) and ensure adequate hydration.
- Pelvic Muscle Exercise (Kegel Exercises): Strengthens pelvic floor muscles to reduce incontinence.
- Prompted Voiding: Regularly reminding and assisting the patient to void to prevent incontinence.
- Self-Care Assistance (Toileting): Helping patients reach or use toilet facilities.
- Specimen Management: Collecting urine samples for diagnostic tests.
- Tube Care (Urinary Management): Managing urinary catheters effectively to prevent infection.
- Urinary Catheterization: Inserting catheters for retention or accurate I&O monitoring.
- Urinary Incontinence Care: Implementing bladder training programs.
- Urinary Retention Care: Using techniques such as the Crede’s maneuver (manual bladder compression).
How to position patient for empty urine
o Male:
Encourage standing if possible.
If in bed, position in semi-Fowler’s position with legs spread and penis directed into a urinal.
Rationale: Men often void more easily while standing.
o Female:
Position in a semi-Fowler’s position if using a bedpan.
Provide support aids such as side rails or trapeze bars to help the patient position herself. Rationale: Women typically void more effectively when sitting upright.
toileting routine
o Identify and maintain the patient’s natural voiding pattern:
Typical times: Upon awakening, after meals, before bedtime, and possibly during the night.
UTI protocol
- Encourage frequent voiding: Every 2-4 hours to prevent stasis.
- Promote perineal hygiene: Clean from front to back (especially important for female patients).
- Encourage adequate fluid intake: To dilute urine and flush bacteria.
- Avoid bladder irritants: Such as caffeine, alcohol, and citrus juices.
What is bladder training for urinary incontinence
Encourage patients to void at scheduled intervals (e.g., every 2 hours).
Urinary diversion care
- Provide proper stoma care: If the patient has a urostomy.
- Monitor urine output and stoma appearance:
o A healthy stoma should be pink or red and moist. - Teach self-care techniques
Measuring effectiveness of interventions
- Voids regularly with urine output of ~1,500 mL/24 hours.
- Demonstrates control over urination.
- Voids without pain, urgency, or dribbling.
- Independently uses toilet or assistive devices.
- Maintains intact perineal skin without redness or breakdown.
Increase fluid intake by
- Keep water or liquids within easy reach
- Remind patients regularly esp for cog impair
- Set daily targets and frequent reminders to hydrate
- Give food w/ lots of water content
- drinks with straws because they’ll drink more. its less effort
- chilled drinks w ice if dry mouth or fever
- juice, herbal tea, flavored water etc
- Keep their mouth in good health. Oral hygiene. Moist swab for NPO.
Who gets peri care
o Incontinence
o Indwelling catheters
o Limited mobility
peri care water temp
warm soapy
Assisting urine void
follow people who ambulate to the bathroom to assist.
if bedridden, use bedpan or bedside commode
Why would be put a urinary catheter in someone
- To collect a sterile urine specimen when a clean catch don’t cut it
- Bladder empty for Dx or Surg
- When Crede’s maneuver fails
- To measure post void residual if bladder scanner didn’t work
- Protect excoriated skin
- Palliative before they die to reduce movement
What types of catheters are there
Indwelling, Intermittent, Suprapubic, Condom
Indwelling cath purpose
Left in place for continuous drainage; has a balloon to hold it inside the bladder.
aka Foley
Long-term drainage, surgeries, urinary retention.
Intermittent Straight Catheter purpose
Inserted for short-term use and removed after the bladder empties.
Post-void residual assessment, urine sample collection.
Suprapubic Catheter
Inserted directly into the bladder through a small abdominal incision.
For patients with urethral damage or long-term catheterization needs
Condom Catheter
External device that fits over the penis to collect urine.
Non-invasive alternative for male incontinence.
Problems with catheter
- Urinary Tract Infections (UTIs): Most common complication due to the catheter creating a direct pathway for bacteria.
o Risk increases with prolonged use of an indwelling catheter.
o Microorganisms can travel along the catheter, causing bladder or kidney infections (bacteriuria or pyelonephritis). - Urethral Trauma: Caused by:
o Using a catheter that is too large.
o Inserting with excessive force or at the wrong angle.
o Poor lubrication during insertion.
Purpose of self catheterization
- Purpose: Helps patients with spinal cord injuries, multiple sclerosis, or chronic urinary retention manage bladder drainage independently.
- Techniques:
o Nurses use sterile technique, but patients performing self-catheterization often use a clean (non-sterile) technique at home. - Advantages:
o Lower risk of infection compared to indwelling catheters.
o Promotes patient independence and quality of life.
Key Point: According to Hooton et al. (2010), intermittent catheterization carries a significantly lower infection risk than indwelling catheters.
CAUTI” protocol
Catheter-Associated Urinary Tract Infection prevention guidelines
Avoid prolonged catheter use
Tips for cathing
- Use the smallest catheter size necessary
- Ensure proper lubrication before insertion
- Maintain a closed drainage system
- Secure the catheter properly
- Perform regular perineal care
- Avoid prolonged catheter use
