Urinary Elimination Skills Flashcards
What is micturition?
Urination. The process of emptying the bladder.
What is the normal amount adults void in a day?
When does the person feel a need to urinate? (Adults/children)
Adults: 1500-1600 mL/day
Urge to void: 250-300 mL (children 50-100mL)
How long is a urethra in a penis and vagina?
Penis 20 cm
Vagina 4 cm
Explain the process of micturition
- Kidneys remove waste from blood and form urine with nephrons
- Ureters transport urine to bladder in peristaltic waves
- Bladder stores urine until urge to urinate (250-300 ml)
- Stretch receptors in bladder send signal to spinal cord
- Signal travels to pontine micturition centre in brainstem
- Signal sent down to relax internal sphincter and detrusor muscle (person becomes aware of urge)
- Conscious relaxation of external urethral sphincter
Factors influencing urinary elimination
- environmental: privacy
- psychological: anxiety, emotional stress (more or less frequents)
- sociocultural: squatting vs sitting vs standing
- fluid balance: oral intake, alcohol, coffee, caffeine
- surgical/diagnostic procedures: cystoscopy can trauma urethra, retention from general anesthetic
- pathological: CNS inability to suppress urge (dementia, stroke, MS), spinal cord injury
- meds: diuretics
What is a concerning amount of urine output?
less than 30 mL/hr
more than 2500 mL/day
*should be roughly equal to input
What are alterations in urinary elimination?
- Urinary Incontinence
- Urinary Retention
- Urinary Tract Infection
- Urinary Diversions
(Ureterostomy,
Nephrostomy)
What are types of urinary incontinence and common causes of each?
- Transient: has a cause and resolves when the underlying cause is treated
CAUSE: DISAPPEAR (delirium, intake of fluids, stool impaction, atrophic vagina, pharmaceuticals, psychological, excess utine output, abnormal lab values, restricted mobility) - Urgency: urge to void cannot be postponed
CAUSE: CNS disorders, obstructions like enlarged prostate - Stress: from increased inter-abdominal pressure
CAUSES: sneezing, laughing, coughing (more common after giving birth) - Mixed: features of stress and urgency
- Associated w/ chronic retention: aka overflow - bladder never completely empties
CAUSES: prostate enlargement, fecal impaction, poor contractibility of bladder muscles, spinal injury - Functional: inability to get to the toilet
CAUSES: cognitive or physical impairments - Multifactorial: releated to factors inside and outside the urinary tact
CAUSES: environmental, meds, age-related changes, obesity, etc.
What are examples of promoting continence?
- lifestyle modification (cutting back on irritating substances, weight loss)
- pelvic floor exercises
- bladder training (suppression techniques)
- habit retraining and prompted voiding
- intermittent catheterizations
- address constipation and fecal impactions
When should you treat a infection in the urinary tract with antibiotics?
only if UTI is symptomatic to avoid ABX use
What is urinary retention?
causes?
acute?
chronic?
- Marked accumulation of urine in the bladder as a result of inability to empty
- CAUSES: underactive detrusor muscle, urethral obstruction
- ACUTE: childbirth/surgery trauma, med side effect, fecal impaction, surgery/anesthesia
- CHRONIC: enlarged prostate, pelvic organ prolapse, urethral stricture (narrow, surgery, STI), alterations to motor or sensory innervation of bladder
How does urinary retention increase risks of UTI and kidney infections?
Prolonged retention → Stagnation/Stasis → Greater Risk of UTI → Kidney Infections
(stagnation of urine can cause urine to be more alkalized, which is more hospitable to bacteria)
What are signs and symptoms of urinary retention?
- Feelings of pressure & discomfort
- Restlessness, diaphoresis (sweating)
- Distended bladder
- Dullness over suprapubic area when percussing
- Absence of urine output (acute)
- Small frequent voiding or dribbling (chronic retention)
What is one way to determine if a patient has urinary retention?
bladder scanner
uses ultrasound to detect urine volume in bladder
How do you manage urinary retention?
- treat the cause
2. intermittent catheter (I and O)
What are the types of urinary catheters?
- intermittent (I and O, straight catheter) - inserted 5-10 mins or just long enough to empty bladder
- Indwelling (Foley catheter) - retained for longer period of time, use a small balloon that keeps catheter in bladder
What are some indications of intermittent catheter use?
To empty the bladder when the patient cannot themselves
- Bladder distension
- Sterile urine specimen
- Assess post-void residual
- Urethral strictures (I&O every time they need to empty)
- Management for patients with SCI, neuromuscular degeneration, incompetent bladder
What are some indications for indwelling catheter?
continuous drainage of urine from the bladder
SHORT TERM:
-Some surgical procedures (during & after)
- Continuous measurement (ex: monitoring fluid imbalance)
- Bladder irrigation
- Prolonged immobilization d/t trauma
- Acute retention/obstruction
- End-of-life (only if required- if changing linen/briefs are too painful)
CHRONIC:
-Chronic retention
- Pressure injury or wounds around the perineal area
- Intractable incontinence (not easily cured or resolved)
Catheter measurements for pediatrics’s, vaginas, and penis?
Peds: 8-10 french
Vagina: 10-12 french
Penis: 12-16 french
what is catheters made out of?
latex - 3 weeks
silcone and teflon - longer term as less buildup around catheter at meatus
In an indwelling catheter. what is the lumens for in a 2 lumen and 3 lumen catheter?
1st lumen: draining
2nd lumen: inflating balloon with sterile water
3rd lumen: for irrigation, to infuse fluid in bladder
How do you insert an
catheter?
→ vagina (10-12 Fr)- 5-7.5 cm (urethra is usually 4 cm) - till you see urine come out, then push in more
→ penis (12-15 Fr) - 22 cm (urethra is 20 cm) - same as above
- Balloon keeps catheter in place.
- Use surgical aseptic techniques
- Clean urethral meatus with the solution in sterile tray
- Lubricate the tip of catheter with water soluble lubricant (also in tray)
- For indwelling - inflate to keep in place after all the urine has drained
How do you provide catheter care?
- perineal care: at least BID, post BM and PRN
- clean around meatus followed by 10 cm of catheter - usually TID (Depends on policy)
- promote fluid intake to flush bladder
- keep system closed as much as possible
what are the potential sites to introduction of infection with catheters?
- At insertion site
- Where tube connects to the Foley
- Where the drainage tubing meets the bag
- The bag itself can be a reservoir for bacteria
- Spigot (where it drains)
What is the number #1 risk of catheterization?
How do you prevent it?
Catheter-Associated Urinary Tract Infection (CAUTI)
PREVENTION:
- Hand hygiene
- Strict aseptic technique
- Maintain a closed system (as much as possible)
- Prevent pooling of urine in tubing
- Avoid kinks in catheter tubing
- Don’t let bag drag on the floor
- Empty drainage bag at least q8h (or ½ full)
- Remove the catheter as soon as clinically possible!! (2-3x risk of death in hospitalized pts)
Catheter Irrigation - what is it and how
Why would it be done
Continuous bladder irrigation (CBI) uses a tripe lumen foley to attach to irrigation bed. NS or sterile water is infused into the bladder and drains into the drainage bag.
- used for pts at risk of clots post-surgery, to maintain paintence of urinary catheter, to administer meds.
(open- opening closed system at catheter and drainage site)
Suprapubic Catheterization:
Indications?
care?
- Surgically placed through abdominal wall above symphysis pubis into bladder (usually sutured)
- used: patients w/ urethral trauma, gynecological procedures, in community and unable to perform self-catheterization
- Cared for similar to indewlling: care for site, closed system, etc.
Condom Catheter?
an alternative to invasive catheters, goes on like a condom for pts w/ penis
(room from tip, tube going to drainage bag)
- standard tape should NEVER be used as penis size can change. Use elastic tape
USED: often for pts w/ nocturia
- Risk: skin breakdown (not a risk of infection)
UTI:
- what is it?
- what can it lead to? treated?
- males vs females?
- Infection of lower urinary tract leading to cystitis, urethritis, and prostatitis (in males)
- Easy to treat (with Abx) but can spread to blood (bacteremia) or kidneys (pyelonephritis)
- Occur more in females – shorter urethra & proximity of rectum to urethral meatus
UTI: Risk factors
RISK: Sexual activity Pregnancy Low levels of vaginal estrogen Obstruction of urinary tract Incomplete bladder emptying Abnormal anatomy Older age Abx (antibiotics) Decreased immunity
UTI: signs and symptoms
Dysuria (pain/burning sensation when urinating) Fever Chills Nausea Vomiting Frequency Urgency Hematuria (blood in urine) Urine concentrated and cloudy (possibly foul smelling)
How do you prevent UTIs
- Promoting good personal hygiene - wipe from front to back
- For recurrent UTI, take showers not baths
- Daily intake of 1500-2000 mL
- Practice frequent voiding every 2-4 hrs
- avoid tight-fitting pants and harsh soaps/sprays in the perineum area
What types of urine test can you perform?
R/M - pH, ketones, protein, glucose, blood, specific gravity; casts (cylindrical bodies that take on shapes of RBC or WBC) is an abnormal finding
→ normal urine pH: 4.6-8, should be no protein/ketones/glucose, no blood but up to 2 RBC is okay, 1.010-1.025 specific gravity to measure concentration
C/S: bacterial growth, determines what antibiotics will be effective
What are methods of urine collection?
- Midstream Urine Collection: package opened w/ aseptic technique, sterile gloves. Use antiseptic cleaner and cotton ball/pour solution to clean peri area. Once stream is initiated, collect urine
- Sterile Urine Specimen: collect using the port on catheter tubing (leurlok- swab port with alcohol and collect)
- Timed Urine Specimen: collect over a given time, depends on order. Start at first void, end at time period.
- Urine dip: specimen in cup, dip strip - chemical reagent strip will test pH, protein, glucose, ketones, blood & specific gravity
Urinary diversions:
- Ureterostomy: bypassing the bladder and urethra as exits routes, and instead using stomas
ex: cancer of bladder, trauma, radiation of bladder, fistula or chronic cystitis - Nephrostomy: drainage tube placed directly into renal pelvis to provide external urinary drainage
Renal Replacement:
Dialysis (peritoneal or hemodialysis) Kidney transplant (long-term option) → peritoneal is usually tried first, and then move to hemodialysis which the pt can be on for a long period of time (then they will explore transplant)
what are some indications for dialysis?
- Renal failure that can no longer be treated with medication or diet modification alone
- Worsening of uremic syndrome in end stage renal disease
- Severe fluid or electrolyte imbalances that cannot be controlled
Peritoneal Dialysis:
Indirect method of cleaning the blood using osmosis and diffusion
- dialysate (sterile electrolyte) goes into peritoneal cavity through gravity and catheter
- distilled in peritoneal cavity for prescribed amount of time
- then drained via catheter and gravity, taking out excess fluid and waste too
- peritoneal cavity acts as a semi-permeable membrane
Hemodialysis:
Machine using semi-permeable filter membrane (to act as an artificial kidney to clean the blood by removing waste and excess fluids)
- blood goes into dialyzer to be filtered, where the process of ultrafilteration, osmosis, and diffusion cleans the pt’s blood
- dialyzer: one side has dialysate (sterile electrolyte solution), other has the patients blood.
Dysuria
painful or difficult urination
Urinary Frequency
voiding more than 8x in 24 hr period
Urinary Hesitance:
difficulty with initiating urination (can happen with no privacy)
Polyuria
voiding large amounts of urine
Oliguria
diminished output (less than 400 mL in 24 hrs)
Nocturia
urinating throughout night
Dribbling
leakage of urine despite voluntary control
Hematuria
blood in urine
elevated post-void residual urine
urine that remains in the bladder after the patient has voided. A significant amount is more than 100 mL remains (normal for 50 mL to remain)
