URINARY ELIMINATION Pamela Llana, MSN, RN

Urinary System

Factors Affecting Urinary Elimination Fluid balance Body position Cognition Psychological factors Sociocultural conditions Surgical/diagnostic procedures Medications Medical conditions

Factors Affecting Urinary Elimination, continued Urinary Tract Infections Most often is a lower UTI Bladder inflammation characterized by dysuria, urgency, and frequency; also referred to as cystitis Females are more at risk anatomically due to shorter urethra

Altered Urinary Function Dysuria Urgency Frequency Polyuria Oliguria

Altered Urinary Function Anuria Nocturia Hematuria Pyuria

Altered Urinary Function Urinary Retention Inability to empty the bladder of urine Can either be inability to empty, to void at all, or overflow voiding Can be caused by obstruction, inflammation/swelling, meds, anxiety, neuro problems Usually involves inability to void or adequately void within 8-10 hours of last voiding. Urine that remains in the bladder after urination is called residual urine. It is normal for <50 mL to remain in the bladder. When assessing, be aware of volume and frequency of voiding.

Altered Urinary Function Urinary Incontinence Involuntary loss of urine from the bladder Not a normal consequence of aging Can be acute/reversible or chronic Can lead to depressive symptoms/social isolation Contributory factor in seeking institutional care

Altered Urinary Function Types of Urinary Incontinence Stress Urge Functional Reflex Total

Altered Urinary Function Enuresis Involuntary voiding after age of voluntary control Usually nocturnal Urinary Diversion Most common cause- cancer Removal of bladder- cystectomy Diversion= ileal conduit; section of ileum dissected out and refashioned for urine drainage

Ileal Conduit

Assessment: Nursing History Normal pattern of urination Symptoms of urinary alteration Factors affecting urinary alteration

Assessment: Physical Assessment Inspection Mucous membranes Urethral meatus As students you will not normally inspect the meatus unless there is a problem. If inspected, pink color with no drainage and smegma are WDL. Palpation Bladder – bulge with 500 mL urine Kidneys

Assessment: Assessment of Urine Intake and output (I & O) Every 8 hrs with 24 hr total I & O should be approx. equal over 24 hrs Characteristics of Urine Volume Color Clarity Odor

Assessment: Specimen Collection Random Timed Sterile Clean voided or midstream Specimen from a catheter

Assessment: Diagnostic Tests Urine Tests Reagent strips pH, glucose, protein, ketones, nitrites, occult blood Urinalysis 20-30 mL min; 1st morning voided spec preferred; detects all above plus bacteria, casts, cells, Specific Gravity = 1.010 – 1.030 Urine for culture and sensitivity sterile spec required; 24 hr minimum time required for culture to grow; another 24 hrs for sensitivity report Blood Tests how well kidneys are working to clean the blood; high levels indicate kidney malfunction or kidney failure; Creat. imp. BUN 6 - 20 mg/dL = normal Creatinine 0.6 - 1.2 mg/dL (serum creatinine) BUN 6-20 = normal Creatinine 0.6-1.2 (serum Cr.)

Assessment: Diagnostic Procedures Imaging Studies are used to visualize urinary system to see calculi, cysts, and tumors Ultrasound can be done at bedside MRI CT scan Radiographic x-ray such as KUB Cystoscopy look into bladder with scope

Nursing Diagnoses Urinary Retention Stress Incontinence Functional incontinence Urge Incontinence Reflex Incontinence Total incontinence Social Isolation

Implementation Promote Normal Voiding Assist with normal position Provide sensory stimuli to aid in elimination Provide for privacy Maintain intake of at least 1500-2000 mL/24 hrs unless contraindicated

Implementation Promote Complete Bladder Emptying Kegel exercises and sit-ups Pelvic floor exercises Tightening perineal and anal muscles Staggering/starting urination Weight reduction relieves pressure on bladder Medications Anticholinergics (Detrol, etc.) Catheterization Necessary if patient is unable to urinate

Implementation Behavioral Interventions Lifestyle modifications Daily fluid intake of 1500-2000 mL Scheduled voiding regimens External catheter Condom catheter Absorbent products Pads, briefs; change frequently to avoid odor and skin breakdown

Implementation Prevent Infection Decrease pH or increase acidity of urine Drink cranberry juice Increase fluids 6-8 glasses/day -OR- 1500-2000 mL/day Void at regular intervals Void at regular intervals; Stagnant urine can increase infections Encourage/promote good hygiene Wipe front to back; Avoid bubble baths, powders, sprays Shower vs. tub bath Voiding before and after intercourse

Implementation Care of Indwelling Catheter Utilize standard precautions Maintain closed system Empty drainage collection bag Positioning of drainage collection bag below insertion/bladder Monitor I & O Cath care after peri-care While holding catheter in place, clean 6-8 inches, wiping away from the body.

Implementation Maintenance of Skin Integrity Keep client as clean and dry as possible Wash with mild soap and water after incontinent episodes. Be sure to rinse soap completely.

I & O sheet INTAKE OUTPUT DATE Oral (po) Tube Fdg IV Totals Urine   Oral (po) Tube Fdg IV Totals Urine Emesis Other 9/10/14 7-3 480 600 1080 500 3-11 320 920 750 200 950 11-7 100 700 300 24 HR Total 24 Hr 2700 1750 24 HR Fluid Balance +950 24 Hr Total 24 HR Total