Urinary elimination care skills Flashcards
1
Q
Micturition
A
- Another way to say voiding
- Process of emptying the bladder
- Normal adult voiding 1500-1600mL/day
- Less than 30mL/hr may indicate renal dysfunction
- Desire to urinate can be sensed with volumes of 250-300mL of urine in an adult bladder
- 50-100mL in a child
- Any urine output < 30mL indicate renal dysfunction
2
Q
Micturition anatomy
A
- Adrenal glands send hormones to the kidney
- Kidneys remove waste from the blood and they form urine; also form red blood cells, blood pressure regulation, bone marrow formation
- Urine removed from kidney through peristalsis waves (not a continuous flow) through the ureters
- Bladder stores urine until urge to urinate develops
- Urine leaves body through urethra
- Vagina; urethra 4cm long
- Penis; up to 20cm long
3
Q
Micturition process
A
1) Stretch receptions in bladder
2) Impulses sent to spinal cord
3) Signals travel to pontine micturition centre in brainstem
4) Signals sent back down resulting in relaxation of internal sphincter and contraction of detrusor muscle
5) Conscious relaxation of external urethral sphincter
4
Q
Factors influencing urinary elimination
A
- Psychological; anxiety, social stress an create sense of urgency and increased frequency; can also prevent people from urinating
- Sociocultural factors; culture/gender/religion, squatting vs sitting technique
- Fluid balance; oral intake, caffeine, alcohol, urine output
- Surgery/diagnostic procedures; looking at bladder through ureters, causes trauma and inability to void; increased risk of urinary retention (increased in older and female patients)
- Pathological conditions; disease that affect CNS (stroke, MS, dementia), result in inability to suppress the ability to void; spinal cord injury can inhibit ability to control holding
- Age; kidney and bladder filtration functions reduces, functional capacity and overall bladder diminished
- Medications; diuretics increase volume of output, anti-colouric side effects can result in inhibited bladder contractility resulting in urinary retention
- Environment; unable to void in certain environments, privacy
5
Q
Promoting urinary elimination
A
- Promote adequate fluid intake; 1500 – 2000 mL daily (adult)
- Maintain normal voiding habits; Q3-4 hours; helps regulate normal bladder capacity
- Encourage regular bowel movements; constipation and impacted stool can compress urethra
- Avoid substances that irritate the bladder such as caffeine, aspartame, carbonated beverages, citrus fruit/juice, alcohol, greasy or spicy foods, tobacco
- Stimulate voiding reflex; run water, pour warm water over perineum, comfortable voiding position
- Promote complete bladder emptying; give them enough time to finish voiding
- Prevent infection; perineal hygiene
6
Q
Assessment: Urinary health history
A
- Patient’s normal voiding patterns
- What’s changed with them
- Normal risk factors; previous history of surgery, medications, typical fluid intake
7
Q
Physical assessment of urinary system
A
- Overall fluid balance (skin turgor, mucus membranes, sweating, cap refill)
- Kidneys (percuss, auscultate)
- Lower abdomen (palpate/percuss)
- Inspect the perineum
8
Q
Assessment of urine
A
Characteristics of urine
- Colour, clarity, odour
- Colour: pale yellow, dark amber, clear
- Clarity; clear or cloudy; cloudy can indicate infection
- Odour; foul smell worth investigating
Intake and output
- Overall amount of urine output
Urine testing and specimen collection
9
Q
Measuring intake and output
A
- Input: IV fluids, dietary fluids, blood products
- Output: urine, diarrhea, emesis, drainage
- Gives us assessment of patient’s overall fluid balance
looking for decrease in urine output - Input should roughly be equivalent to output
- I&O usually ordered by physician, but depends on unit; can be initiated by RN as well
- Hourly output <30mL/Hr is cause for concern
- Any more than >2500mL/day is cause for concern
10
Q
Initiating I&O
A
Initiate if:
- Worried if patient has urinary retention,
- After surgery,
- Patient has any type of renal issues,
- Fluid balance with patients with congestive heart failure
- Patients who have large volumes of diuretics to ensure meds are working
11
Q
How to measure output
A
Graduated cylinder
- From a foley catheter
- Get a more accurate reading of outs
Urometer
- Tilt bag forward so all move into urometer
- So you don’t have to pour out
Urine hat
- Goes directly into toilet so they can measure
- For other losses we don’t measure but record (i.e. number of time vomited, excess sweating)
- Usually measure wound drainage
12
Q
Alterations in urinary elimination
A
- Urinary incontinence
- Urinary retention
- Urinary tract infections
- Urinary diversions (ureterostomy, nephrostomy)
13
Q
Symptoms of urinary alteration
A
- Incontinence; involuntary loss of urine
- Urgency: sudden and compelling urge to void that cannot be postponed
- Dysuria; painful/difficult urination
- Frequency; voiding more than 8 times in a 24Hr period
- Hesitancy; difficult with initiating urination
- Polyuria; voiding large amounts of urine
- Oliguria; diminished output, usually <400Ml/24Hrs.
- Nocturia; getting up in the night to void, often occurs in patients with enlarges prostates
- Dribbling; leakage of urine despite voluntary control
- Hematuria; presence of blood in the urine , sever UTI, post prostate surgery
- Elevated post-void residual urine; urine that remains in the bladder after the patient has voiding; significant if more than 100mL remaining
14
Q
Factors influencing urinary incontinence
A
- Transient; usually has cause and resolves once underlying cause treated
- Urgency; cannot suppress urge to void, causes are CNS disorders or obstruction like an enlarged prostate
- Stress; increased intra-abdominal pressure; laughing too hard, sneezing, coughing, mainly patients who have a vaginal or who have given birth
- Mixed; features of both stress and urgency
- Associated with chronic retention; overflow retention, associated with bladder never being able to completely empty, prostate enlargement or fecal impaction, can result from poor contractility from spinal cord injury
- Functional; inability to get to toilet, cognitive (not knowing where toilet is), physical (can’t get to toilet)
- Multifactorial; related to a number of different factors, both inside and outside; medications, age related changes, environmental factors
- Incontinence is not a normal part of aging; not an expected finding
- While there are normal age related variations, continence should not be affected
15
Q
Transient incontinence causes: DISAPPEAR
A
D (delirium) I (intake of fluids) S (stool impaction) A (atrophic vaginitis P (psychological problems) P (pharmaceuticals) E (excess urine output) A (abnormal lab values; hyper glycemia) R (restricted mobility)
16
Q
Promoting continence
A
- Lifestyle modification; reduce caffeine consumption, cut back of irritating substances, weight loss (obesity can contribute to incontinence)
- Pelvic flood exercises; increase muscle tone
- Bladder training; gradually increasing interval between voids to decrease incontinence, thinking about something else
- Habit training/prompted voiding; good for cognitive/physical impairments and those who have caregiver
- Intermittent catheterization; can do alone or we can do it for them
- Medications; can promote continence
- Maintaining skin integrity ; providing good peri care to prevent infection
17
Q
RNAO ways of promoting continence
A
- Assess for presence of infection ONLY if indicated; deter the use of unnecessary antibiotics
- Address constipation and fecal impaction
- Identify environmental barriers; toilet close enough, adequate lighting, restraint use
- Identify staff attitudinal barriers
- Ensure adequate fluid intake, reduce caffeine and alcohol
- Assess and monitor voiding patterns
- Provide staff education; incontinence is not a normal age related process
- Use an interprofessional team approach; important to get people involved, takes a lot of people to have success
18
Q
Urinary retention
A
- “Marked accumulation of urine in the bladder as a result of inability of the bladder to empty”
Causes:
- Under active or not working detrusor muscle
- Urethral obstruction
Acute:
- Surgical or childbirth trauma
- Medication side effects
- Fecal impaction
- Surgery/anesthesia
Chronic
- Enlarged prostate
- Pelvic organ prolapse; uterus ligaments stretched out, uterus and bladder can fall out of place
- Urethral stricture; opening becomes narrower due to trauma or STIs
- Alterations in motor and sensory innervation of the bladder
19
Q
Signs and symptoms of urinary retention
A
- Feelings of pressure & discomfort in lower abdomen
- Restlessness, diaphoresis; especially in patients who cannot communicate voiding need
- Distended bladder
- Dullness over suprapubic area
- Absence of urine output (acute)
- Small frequent voiding or dribbling; chronic retention, bladder can only hold so much then begins to leak out
- Prolonged retention; stagnation/stasis; greater risk of UTI; kidney infection
- As urine is retained in bladder in becomes stagnent and more akalined and it’s more hospital to bacteria
- If UTI not treated it can go up uterurs and get into kidney causing kidney infection
20
Q
Bladder scanner
A
- Ultrasound technology using high-frequency sound waves to detect urine volume in bladder
- Quick and painless method of assessing residual urine in bladder
21
Q
Managing urinary retention
A
Treat the cause
- e.g. change medication, prostate surgery, etc.
Intermittent catheter
- Or indwelling
22
Q
Urinary catheterization
A
- Introduction of a catheter through the urethra into the urinary bladder
Intermittent:
- Also called straight or in-and-out
- Inserted for ~5-10 minutes or just long enough to empty the bladder.
- Performed by nurse or patient
- Sterile in hospital, clean in community
Indwelling:
- Retained for longer using small balloon that keeps catheter in the bladder
- Sterile technique
