Mosby items and derived items © 2005 by Mosby, Inc. Chapter 45 Urinary Elimination Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Urinary System Kidneys Remove waste from blood to form urine Nephron Functional unit of kidney, forms the urine Normal adult urinary output 1500-1600 ml/day 30 ml/hr Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Urinary System Ureters Transport urine from kidneys to bladder Renal colic Caused by strong peristaltic waves attempting to move obstruction Bladder Holds urine until urge to urinate develops Urethra Urine travels through urethra and passes outside of body through urethral meatus Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Urinary System Women 1.5 to 2.5 inches Predisposed to infection Men 8 inches Act of urination (micturition, void) Bladder holds 600 ml Desire to void at 150-200ml Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Disease conditions Prerenal alterations Decrease circulating blood flow to and through kidneys with resulting decreased blood flow to renal tissue Oliguria Diminished capacity to form urine Anuria Inability to produce urine Causes Dehydration, hemorrhage, congestive heart failure Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Renal alterations Injury directly to glomeruli or renal tubule, interfering with normal filtering, reabsorptive and secretory functions Causes Transfusion reactions, diseases of glomeruli, systemic diseases (DM) Post renal alterations Result from obstruction to urine flow in urinary collecting system Calculi, blood clots, tumors Urine is formed by body but can’t be eliminated by normal means Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination DM and MS, Alzheimers dz Neuropathic conditions, cognitive impairments Rheumatoid arthritis, DJD, Parkinson’s End stage renal disease (ESRD) Irreversible damage to glomerulus or tubules Uremic syndrome Increase nitrogenous wastes in blood, altered regulatory functions n/v, HA, coma and convulsions Require renal replacement therapies: dialysis and organ transplantation Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Sociocultural factors Degree of privacy cultural Psychological factors Anxiety and emotional stress Cause sense of urgency and increased frequency Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Muscle tone Weak abdominal and pelvic floor muscles Impair bladder contraction and control of external urethral sphincter foley Fluid balance Volume of food and fluid intake Polyuria Excessive urinary output Nocturia Causes Ingestion of caffeine products: coffee, tea, coco and cola Alcohol Foods with high fluid content Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Surgical procedures Anesthetics and narcotics may decrease urine output Impair urge to void, sense of bladder fullness Edema and trauma after surgery Urinary diversion Stoma Bypasses bladder and urethra Temporary or permanent Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Urination Medications Diuretics Increase urinary output Meds that change color or urine Pyridium, Amtriptyline Meds that cause urinary retention Antihistamine, anticholinergics Diagnostic examinations Treatment/requirements before procedure may limit intake Edema Urinary retention Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Alterations Urinary retention Bladder unable to respond to micturition reflex unable to empty Urethral obstruction, surgical or childbirth trauma, alterations in motor and sensory innervations Urinary tract infections Most common cause of nosocomial infections Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Alterations E. coli Responsible for 80% Symptoms Dysuria, hematuria, fever, chills, n/v, malaise If infection spreads to upper part of urinary tract (kidneys) Pyelonephritis Flank pain, tenderness, fever and chills Urinary incontinence Involuntary loss of urine Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Alterations Temporary or permanent 15-30% women Present 50% nursing home residents 15-56% homebound Geriatric Urinary diversions Urinary stoma to divert flow of urine from kidneys directly to abdominal surface CA bladder, trauma, fistulas) Ileal loop Ureterostomy Nephrostomy Continent urinary diversion Mosby items and derived items © 2005 by Mosby, Inc.

Urinary Incontinence (p. 1349) Functional Involuntary, unpredictable passage of urine in client with intact urinary and nervous system Sensory, cognitive or mobility deficits Overflow Voluntary or involuntary loss of a small amount of urine from over distended bladder Fecal impaction, DM, spinal cord injuries, prostrate enlargement, prolapsed uterus Reflex Mosby items and derived items © 2005 by Mosby, Inc.

Urinary Incontinence (p. 1349) Involuntary loss of urine, occurs predictable intervals Spinal cord dysfunctions Stress Leakage of small amt of urine caused by sudden increase in intrabdominal pressure Coughing, laughing, sneezing Urge Involuntary passage urine after strong sense of urgency Decreased bladder capacity, increased fluid intake Mosby items and derived items © 2005 by Mosby, Inc.

Infection Control and Hygiene Asepsis Client education Catheterization and other procedures Mosby items and derived items © 2005 by Mosby, Inc.

Growth and Development Infants Excretes 400-500 ml/day Toddlers and young children Associates sensation bladder fullness and urination at 2-3 years Adults 1500-1600 ml/day Mosby items and derived items © 2005 by Mosby, Inc.

Growth and Development Older adults Prostates enlargement Urinary frequency and/or urinary retention Urgency and stress incontinence Altered mobility Nocuturia Urinary frequency Bladder loses muscle tone Residual urine Bladder doesn’t contract as effectively Mosby items and derived items © 2005 by Mosby, Inc.

Psychosocial Considerations Self-concept Culture Gender Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Urinary Elimination Nursing history Pattern of urination Symptoms of alteration Factors affecting urination Bowel elimination Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Urinary Elimination (cont'd) Physical assessment Skin and mucous membranes Kidneys Bladder Urethral meatus Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Urinary Elimination (cont'd) Assessment of urine Intake and output Characteristics: color, clarity, odor Urine testing: specimen collection Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Urinary Elimination (cont'd) Common urine tests (p. 1339) Urinalysis pH 4.6-8 acidic Specific gravity 1.010-1.025 High-concentrated urine Dehydration, reduced renal flow Low-diluted Overhydration, early renal disease Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Urinary Elimination (cont'd) Culture and Sensitivity 24-48 hours Diagnostic examinations Consents Allergies Shellfish, iodine, latex Pre- and postprocedure interventions NPO, enemas, etc I&O, urine characteristics Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Nursing Diagnoses Incontinence Risk for infection Toileting self-care deficit Impaired urinary elimination Urinary retention Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Planning Goals and outcomes Client will void within 8 hours after catheter removal Client’s bladder is not distended on palpation Setting priorities Continuity of care Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Health Promotion Client education Promoting normal micturition: stimulation of reflex, maintenance of habits and fluid intake Intake 2000-2500 ml/day Elimination of fluids 2 hours before bedtime Promoting complete bladder emptying (table 44-5) Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Health Promotion Preventing infection: hygiene and acidifying urine Acidic foods Meats, eggs, whole grain breads, cranberries, prunes Cranberry juice Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Acute Care Maintaining elimination habits Medications Urethral catheterization Alternatives to urethral catheterization: suprapubic catheters, condom catheters Mosby items and derived items © 2005 by Mosby, Inc.

Urethral Catheterization Types Insertion Drainage systems Routine care: hygiene, fluids Prevention of infection Irrigations and instillations Removal Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Restorative Care Strengthening pelvic floor muscles Kegel Bladder retraining (p. 1368) Habit training Self-catheterization Every 6-8 hours Maintenance of skin integrity Promotion of comfort Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Evaluation Client care Client expectations Mosby items and derived items © 2005 by Mosby, Inc.