Urinary elimination Flashcards
Where are the kidneys located?
Posterior wall
T12-L3
What is the flow of urine?
Kidneys -> ureters -> bladder -> urethra -> outside
What vessel is the major blood supply for the kidneys?
Renal artery
How is urine brought from the kidneys to the bladder?
It’s dumped into the pelvis and brought to the bladder
Why is blood pressure important?
Essential for filtration (Bowman’s capsule)
What does filtrate consist of?
Water, glucose, amino acids, urea, creatinine, electrolytes
All will pass through the Bowman’s capsule/basement membrane
What is normal daily urine output?
1200-1500 mL
When should you be concerned about urine output?
When there’s <30 mL for 2 consecutive hours
What are the roles of the kidney
Filter blood Compose urine Produce erythropoietin Produce renin Ca+ and phosphate regulation
What part of the kidney filters blood?
Nephron
What people are prone to anemia?
People with kidney disease
How do kidneys affect blood pressure?
Renin released -> converts angiotensinogen to angiotensin 1 -> AGT 2 in lungs -> vasoconstriction -> more blood flow to kidney
- Renin stimulates aldosterone release -> Na+ and H20 absorption -> increase blood volume
What is the anterior pituitary’s role in blood pressure?
ADH secreted there
Responds to increase in osmolality in blood -> ADH released -> kidneys reabsorb more water to maintain fluid balance
What minerals are regulated by the kidneys?
Ca+ and K+
What happens in kidney disease?
Can’t convert Vitamin D to its active form
Prone to bone disease because of impaired absorption
What are the ureters?
Tubular structures with peristaltic waves
Extend to urinary bladder
What is a renal colic?
Obstruction of the ureter (kidney stone)
What is the bladder?
Hollow, distensible, muscular organ (detrusor)
Urine reservoir
Where is the bladder located?
Located in front of the uterus and vagina in females
In males, located in front of the rectum and above the prostate gland
How much urine does the bladder hold?
600 mL - 1000 mL
How is the bladder affected by hysterectomies?
Can tip backwards
What is the urethra?
Carries urine from bladder out of the body via urethral meatus
How long is the urethra?
Females: 1.5 – 2.5” long, located between labia minora; above vagina
Males: 8” long; located at distal end of penis
Where is the urethra located?
Urethra descends from bladder through smooth muscle and pelvic floor muscles
How does the act of urination occur?
Bladder wall stretches
Sensory impulses are sent to the micturition center
Internal urethral sphincter relaxes – (urine enters urethra)
Impulses sent to the brain
Person is conscious of the need to urinate
Impulses are ignored or responded to voluntarily
Ignore: external urinary sphincters contract and micturition reflex is inhibited.
Responded: external sphincter relaxes - micturition reflex stimulates bladder contraction
Bladder wall stretches -> sensory impulses sent to micturition center in spinal cord sacral level -> internal sphincters relax -> urine enters urethra -> impulses sent to brain and person becomes conscious of need to urinate -> external urinary sphincters can contract (preventing peeing) or relax -> micturition reflex stimulates bladder to contract and pelvis floor muscles relax
What are some tips for health promotion?
Assume normal position (women vs men)
Promote relaxation
Maintain adequate fluid intake (2L) and voiding routines.
Encourage patient to wait until urine flow stops or attempt to void again can improve bladder emptying
Good perineal hygiene
What affects voiding?
Depends upon feeling the urge, being able to control the urethral sphincter and being able to relax during urination. Avoid fluids 2 hours before bedtime to reduce nocturia
What factors can affect urination?
Stress can cause muscles to become tense -> issues initiating flow of urine
Hearing running water, pouring warm water over perineum can help
Why is insufficient emptying of the bladder bad?
Leads to urinary stasis -> increased UTI risk
What is urinary retention?
Inability to empty the bladder
150-250 ml or 25% of total bladder capacity remains in bladder after voiding
Unable to feel fullness or urine is unable to pass outside the body
What is the etiology of urinary retention?
Urethral obstruction (enlarged prostate gland or urethral edema after childbirth)
Alterations in motor or sensory innervation
Post-op patients (anesthesia)
After removal of indwelling catheter
Medication - Antihistamines and anticholinergics
How can an indwelling catheter cause urinary retention?
Bladder loses some tone because it didn’t have stretching and relaxing of bladder with catheter in
What does the nursing assessment consist of for urinary retention?
History: Do you have any difficulty starting your urinary stream?
Palpation from umbilicus to symphysis pubis
Bladder scan if available
Absence of urine output, or voided small frequent amounts (retention overflow)
Discomfort- severe pain
What are interventions for urinary retention?
Health Promotion: encourage voiding every 4 hours; assess patient’s voiding routine;
Privacy
Listen to running water; pour water over the perineum; offer a beverage
Medications - Stimulate bladder contraction (cholinergic drugs)
Catheterization – Acute urinary retention or obstruction
What is urinary incontinence and what are the 5 types?
Functional Reflex Stress Urge Total
What is functional incontinence?
Inability or unwillingness of a person with normal bladder and sphincter control to reach the bathroom in time to void
What types of people get functional incontinence?
People with sensory & cognitive limitations
Motor deficits
- Ex: impaired gait
- Ex: fine motor - clothing
Environmental limitations – cluttered room wheelchair access to bathroom, no bathroom on first floor of home
What are some interventions for functional incontinence?
Modification of environment, clothing
Scheduled voiding/toileting
What is reflex incontinence?
Involuntary loss of urine when a specific bladder volume is reached (overcomes sphincter)
What types of people have reflex incontinence?
Neurological impairment above level of micturition center (SCI; CVA)
What are some interventions for reflex incontinence?
Intermittent catheterization
Suprapubic tube
Medications to relax sphincter control
What is stress incontinence?
Leakage of small amount of urine with sneeze, cough, jumping. Usually small amounts of urine.
What causes stress incontinence?
Relaxed pelvic floor muscles
Childbirth
Post-menopause – sphincters relax, urethra and bladder become less elastic
Prostate surgery for benign prostatic hypertrophy (BPH) or prostate cancer
Increased intrabdominal pressure
Obesity
What are interventions for stress incontinence?
Strengthen pelvic floor muscles Kegels Weight loss if obese Surgical interventions Topical estrogen products Absorbent products/external catheter
What is urge incontinence?
Involuntary passage of urine after a strong urge to void
Usually a large amount of urine
Overactive detrusor muscle – excessive contraction of the muscle
What can cause urge incontinence?
Decreased bladder capacity Infection Diuretics Alcohol Removal of indwelling catheter Overactive bladder (OAB): uncontrolled contraction of the bladder muscles
What are the 4 major symptoms of OAB?
Urinary urgency
Urinary frequency (>8x/24 hours)
Nocturia
Urge incontinence
What populations most frequently see urge incontinence?
Elderly
What are interventions for urge incontinence?
Timed voiding schedule (q2h)
Timing fluid intake appropriately
Kegels
Reduce bladder irritants (smoking; caffeine)
Drug therapy - Anticholinergic medication approved for OAB
- Oxybutynin (Ditropan); Tolterodine (Detrol); Solifenacin (VESIcare)
How do anticholinergic drugs work to stop urge incontinence?
Block muscarinic receptors -> suppress bladder contraction
What are side effects of anticholinergic drugs?
Urinary hesitancy (starting stream is harder), dry mouth, dry eyes, constipation
What is total incontinence?
Continuous, unpredictable loss of urine
What are interventions for total incontinence?
Toileting routines
External catheters for men
Absorbent products
Excellent skin care and hygiene
What causes UTIs?
Residual urine in bladder
Catheterization – 80% of UTIs; most common HAI - CAUTIs
Fecal incontinence or poor perineal hygiene
What are symptoms of UTIs?
Dysuria, frequency, urgency, pyuria or hematuria
What are symptoms of UTIs in the elderly?
May not have urinary symptoms
Instead: confusion or change in mental status
What is dysuria?
Painful urination
What is pyuria?
WBC in urine
What are health promotion techniques for preventing UTIs?
Good perineal hygiene Void every 4 hours Adequate fluid intake - (high acidity) Voiding after sexual intercourse Women - avoid tight fitting pants, harsh soaps, bubble baths and powders.
How does cranberry juice affect UTIs?
Use as preventative method for UTIs has not been definitively established
Repeat UTIs – 2 in 6 months or 3+ a year
- Seems to help
What are manifestations of UTIs?
Urinalysis (UA) - Nitrates – produced by bacteria - White blood cells (WBCs) - Bacteria Culture and sensitivity - Predominant organism – If multiple organisms are found in small amounts -> indicated contamination of specimen - Must be a clean catch
What are interventions for UTIs?
Antibiotics
Phenazopyridium for symptoms
Adequate fluid intake
What are interventions for repeat UTIs?
Nitrofurantoin (Macrobid, Macordantin)
- Ongoing use
- Decreases bacteria count in residual urine
What is a urostomy?
Urinary diversion
- Continent urinary reservoir created from a distal portion of the ileum and proximal portion of the colon. Sits under abd wall, ileal segment is brought through wall and acts as a stoma.
Is a urinary diversion continence or incontinence?
Continent urinary reservoir because it won’t leak out, but person will catheterize their self to release urine
How do you assess urine?
I/O
Color - straw colored
Clarity - should not be cloudy
Odor - no/mild odor
What should be looked for in urine testing?
Urinalysis - pH (4.6-8) - protein - none-trace - glucose-none - ketones-none - blood-none - specific gravity (1.005-1.030) Urine culture - Midstream (clean catch) - Sterile (obtained from catheter) Timed tests: 24 hour urine Serum tests: BUN, creatinine
What are the types of urinary catheterization?
Intermitten
Indwelling (foley)
How do you insert a foley?
Handwash, sterile procedure, clean urethral opening, advance lubricated catheter until urine return, then advance another 2 inches and inflate balloon, gently pull back until resistance is felt and secure to upper thigh
How do you care for foleys?
Cleanse perineal area and catheter qd and after each BM
Maintain closed system
Adhesive-backed securement device to patient’s thigh - hold catheter in place
Collection bag below the level of the bladder – attach to bed frame
Empty drainage bag q8h
Special care for Bladder Catheter Irrigation
REMOVE AS SOON CLINICALLY NECESSARY – Expect voiding within 6-8 hours post removal
