1. Mosby items and derived items © 2005 by Mosby, Inc.
Chapter 45
Urinary Elimination
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2. 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
ml/day
30 ml/hr
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3. 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
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4. 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 ml
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5. 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
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6. 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
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7. 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
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8. Factors Influencing Urination
Sociocultural factors
Degree of privacy
cultural
Psychological factors
Anxiety and emotional stress
Cause sense of urgency and increased frequency
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9. 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
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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
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16. 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
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17. Infection Control and Hygiene
Asepsis
Client education
Catheterization and other procedures
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18. Growth and Development
Infants
Excretes ml/day
Toddlers and young children
Associates sensation bladder fullness and urination at 2-3 years
Adults
ml/day
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19. 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
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20. Psychosocial Considerations
Self-concept
Culture
Gender
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21. Assessment of Urinary Elimination
Nursing history
Pattern of urination
Symptoms of alteration
Factors affecting urination
Bowel elimination
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22. Assessment of Urinary Elimination (cont'd)
Physical assessment
Skin and mucous membranes
Kidneys
Bladder
Urethral meatus
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23. Assessment of Urinary Elimination (cont'd)
Assessment of urine
Intake and output
Characteristics: color, clarity, odor
Urine testing: specimen collection
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24. Assessment of Urinary Elimination (cont'd)
Common urine tests (p. 1339)
Urinalysis
pH acidic
Specific gravity
High-concentrated urine
Dehydration, reduced renal flow
Low-diluted
Overhydration, early renal disease
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25. 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
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26. Mosby items and derived items © 2005 by Mosby, Inc.
Nursing Diagnoses
Incontinence
Risk for infection
Toileting self-care deficit
Impaired urinary elimination
Urinary retention
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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
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28. Implementation: Health Promotion
Client education
Promoting normal micturition: stimulation of reflex, maintenance of habits and fluid intake
Intake ml/day
Elimination of fluids 2 hours before bedtime
Promoting complete bladder emptying (table 44-5)
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29. Implementation: Health Promotion
Preventing infection: hygiene and acidifying urine
Acidic foods
Meats, eggs, whole grain breads, cranberries, prunes
Cranberry juice
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30. Implementation: Acute Care
Maintaining elimination habits
Medications
Urethral catheterization
Alternatives to urethral catheterization: suprapubic catheters, condom catheters
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31. Urethral Catheterization
Types
Insertion
Drainage systems
Routine care: hygiene, fluids
Prevention of infection
Irrigations and instillations
Removal
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32. 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
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33. Mosby items and derived items © 2005 by Mosby, Inc.
Evaluation
Client care
Client expectations
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