Urinary Elimination

The term elimination is defined as the excretion of waste products. Concept: Elimination Definition: The term elimination is defined as the excretion of waste products. Bowel Elimination Bowel elimination is defined as the passage of stool through the intestinal tract and dispelling the stool by means of intestinal smooth muscle contraction. Urinary Elimination Urinary elimination is defined as the passage of urine through the urinary tract by means of the urinary sphincter and urethra.

Risk Factors for Problems of Elimination Conditions that result in Neurologic impairment (Neurogenic bladder) Trauma to the brain or spinal cord CVA Diabetic neuropathy (R/T metabolic derangements) Altered mobility Severe arthritis Cognitive impairment dementia Immunologic impairment or infection AIDS

Scientific Knowledge Base: Organs of Urinary Elimination Kidneys Remove waste from the blood to form urine Ureters Transport urine from the kidneys to the bladder Bladder Reservoir for urine until the urge to urinate develops Urethra Urine travels from the bladder and exits through the urethral meatus.

Urinary System Urinary System Organs Renal Nephron

Additional Kidney Functions Production of erythropoietin is essential to maintaining a normal red blood cell (RBC) volume. Erythropoietin stimulates bone marrow to produce RBCs and prolongs the life of mature RBCs. Production of renin. Renin starts a chain of events that cause water retention, thereby increasing blood volume. Kidneys affect calcium and phosphate regulation

Renin-Angiotensin Mechanism

Kidneys affect calcium and phosphate regulation Vitamin D The Kidneys produces a substance that converts vitamin D into its active form. Intestines absorb more Ca from foods.

Factors Influencing Urination Disease conditions Socioeconomic factors (need for privacy) Psychological factors (anxiety, stress, privacy) Fluid balance Nocturia, polyuria, oliguria, anuria Diuresis Fever Medications and medical procedures

Disease Conditions Affecting Urination Prerenal, renal, postrenal classification Conditions of the lower urinary tract Diabetes mellitus and neuromuscular diseases such as multiple sclerosis Benign prostatic hyperplasia Cognitive impairments (e.g., Alzheimer’s) Diseases that slow or hinder physical activity Conditions that make it difficult to reach and use toilet facilities End-stage renal disease, uremic syndrome

Pre-renal, renal, post-renal classification Decrease blood flow Condition of renal tissue Obstruction in the UT that prevents flow from kidneys

Conditions of the Lower Urinary Tract

Diabetes Mellitus and Neuromuscular Diseases

Benign Prostatic Hyperplasia (BPH)

Conditions Affecting Urination Conditions that make it difficult to reach and use toilet facilities Cognitive impairments Diseases that slow or hinder physical activity

End Stage Renal Disease (ESRD) (CKD)

Dialysis Renal Replacement Two methods Peritoneal Hemodialysis

Indications for Dialysis Renal failure that can no longer be controlled by conservative management (Conservative management would include dietary modifications and the administration of medications to correct electrolyte abnormalities.) Worsening of uremic syndrome associated with ESRD, which would include nausea, vomiting, neurological changes, and pericarditis) Severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures (These abnormalities would include hyperkalemia and pulmonary edema.) by simpler measures

Factors Influencing Urination Disease conditions Socioeconomic factors Need for privacy Cultural differences Psychological factors Anxiety Emotional Stress Privacy

Factors Influencing Urination Fluid balance Nocturia, polyuria, oliguria, anuria Diuresis Fever Foods Medications and medical procedures

Fluid Balance Symptoms common to urinary disturbances include frequency urgency dysuria polyuria oliguria incontinence difficulty in starting the urinary stream.

Medications and Medical Procedures Surgery (stress)

Alterations in Urinary Elimination Urinary retention An accumulation of urine due to the inability of the bladder to empty Urinary tract infection Results from catheterization or procedure Urinary incontinence Involuntary leakage of urine Urinary diversion Diversion of urine to external source

An accumulation of urine due to the inability of the bladder to empty Urinary Retention An accumulation of urine due to the inability of the bladder to empty Signs and Symptoms Bladder distention No UO in several hours May void small amounts of urine 2-3 times an hour Treatment Residual urine Bladder scan I & O catheter

Urinary Tract Infection Results from catheterization or procedure CAUTIs (Catheter-associated UTIs) Increased hospitalization Increased morbidity and mortality Longer hospital stay Increased hospital cost

Urinary Tract Infection 7 reasons for insertion of a Foley Catheter Urinary retention To relieve urinary obstruction Accurate I&O in critical patients Bladder decompression for surgery Urinary incontinence with stage 3 – 4 pressure ulcers Comfort for terminal patient Urological procedurss

Urinary Tract Infection Signs and symptoms Pain or burning during urination (dysuria) Fever, chills, nausea, vomiting, and malaise Frequent and urgent sensation of need to void Blood-tinged urine (hematuria) Treatment Medication

Urinary incontinence CVA, Heat injury, spinal cord injury, diabetic neuropathy, irritating factors

Nursing Diagnoses Impaired Social Interaction r/t Loss of independence: clothing becomes wet with urine and odor. Impaired body image r/t incontinent of urine. Risk for impaired skin integrity.

Nursing Knowledge Base & Assessment Infection control and hygiene Growth and development Muscle tone Psychosocial considerations Cultural considerations

Physical Assessment Gather nursing history for the patient’s urination pattern and symptoms, and factors affecting urination. Conduct physical assessment of the patient’s body systems potentially affected by urinary change. Assess characteristics of urine. Assess the patient’s perception of urinary problems as it affects self-concept and sexuality. Gather relevant laboratory and diagnostic test data.

Physical Assessment Skin and mucosal membranes Kidneys Bladder Assess hydration. Kidneys Flank pain may occur with infection or inflammation. Bladder Distended bladder rises above symphysis pubis. Urethral meatus Observe for discharge, inflammation, and lesions.

Assessment of Urine Intake and output (I&O) Characteristics of urine Color Pale-straw to amber color Clarity Transparent unless pathology is present Odor Ammonia in nature Urine testing Specimen collection

Urine Tests and Diagnostic Examinations Urinalysis Specific gravity Culture Noninvasive procedures Invasive procedures

Catheterization Catheter insertion Closed drainage systems Catheter care Perineal hygiene Fluid intake Catheter irrigations and instillations Removal of indwelling catheter Alternative to urethral catheterization

Types of Urinary Catheters Intermittent and indwelling retention catheterizations are the two forms of catheter insertion. With the intermittent technique, you introduce a straight single-use catheter (A) long enough to drain the bladder (5 to 10 minutes). When the bladder is empty, you immediately withdraw the catheter. You can repeat intermittent catheterization as necessary, but each catheter insertion increases risks of trauma and infection. It is common for people with spinal cord injury or other neurological problems such as multiple sclerosis to perform self–intermittent catheterization up to every 4 hours daily for months or years. If done correctly with the use of clean technique, they frequently do not experience more UTIs; in fact, the UTI rate is lower than for patients with long-term indwelling catheters. An indwelling or Foley catheter (B) remains in place for a longer period—until a patient is able to void voluntarily, or until continuous accurate urine measurements are no longer needed. A second type of intermittent catheter has a curved tip. A Coudé catheter is used on male patients who may have enlarged prostates that partially obstruct the urethra. It is less traumatic during insertion because it is stiffer and easier to control than the straight-tip catheter. Catheters are available in many diameters to fit the size of a patient’s urethral canal. [Box 45-8 on text p. 1062 provides suggestions for how to make appropriate decisions regarding catheter selection.] [Shown is Figure 45-12 from text p. 1061.]

Urinary Drainage System and Infectious Organisms

Applying a Condom Catheter The condom catheter is suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying. The condom is a soft, pliable, latex sheath that slips over the penis. Patients wear it only at night or continuously, depending on their needs. After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP). Be sensitive to the privacy needs of patients. Be sure that the skin of the penile shaft is intact and free from swelling, redness, or open lesions before applying the condom catheter. Ask for assistance if the NAP is uncertain how to apply the adhesive strip that secures the condom catheter. [Image shows the distance between the end of the penis and the tip of the condom = Step 12 on text p. 1065 Box 45-11 Procedural Guidelines: Applying a Condom Catheter.] [See Box 45-11 Procedural Guidelines: Applying a Condom Catheter on text p. 1065.] Three general methods may be used to secure a condom catheter: 1. The first method uses a strip of elastic tape or rubber that encircles the top of the condom to secure it in place. 2. Another type uses a self-adhesive condom sheath. 3. The third method uses an inflatable ring within the condom to secure placement. Take care to ensure that, whatever type or size is used, blood supply to the penis is not impaired. Never use standard adhesive tape to secure a condom catheter because it does not expand with change in penis size and is painful to remove. After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP). [Image shows the application of elastic tape in a spiral fashion to secure condom catheter to penis = Step 13a on text p. 1065, Box 45-11 Procedural Guidelines: Applying a Condom Catheter.]

Applying a Condom Catheter (cont’d)

External Urinary Device

Restorative Care Strengthening pelvic floor muscles Bladder retraining Habit training Self-catheterization Maintenance of skin integrity Promotion of comfort