Urinary Elimination and Diversions

Urinary Elimination Overview

• A precise system involving filtration, reabsorption, and excretion that maintains fluid and electrolyte balance by filtering and excreting water-soluble wastes.
• The kidneys are the primary organs, with nephrons performing most filtration and elimination functions, producing 1,000 to 2,000 mL of urine daily in adults.
• Urine flows from the kidneys through the ureters to the bladder
• The bladder acts as a storage reservoir
• 250 to 450 mL of urine collect in the bladder in adults
• Stretch receptors signal the brain to indicate the need to urinate, resulting in the relaxation of internal and external sphincters and urine exiting the body through the urethra.
• Surgery, immobility, medications, and therapeutic diets can impact urinary elimination.

Urinary Diversions

• Surgical rerouting of urine flow, can be temporary or permanent.
• Often performed for clients with bladder cancer or injury.
• Share similarities with bowel diversions, including body image concerns.
• Can be continent (controlled elimination) or incontinent (continuous drainage).
• Continent diversions involve a reservoir in the abdomen for controlled urine elimination.
• Ureterostomy (ileal conduit): Incontinent diversion attaching ureters to a stoma on the abdomen.
• Nephrostomy: Incontinent diversion attaching a tube from the renal pelvis to a stoma on the abdomen.
• Kock pouch: Continent diversion creating a reservoir from the ileum, emptied via catheterization every 2-3 hours initially, then every 5-6 hours.
• Neobladder: New bladder created from the ileum, allowing continence through straining abdominal muscles.
• Nursing interventions should involve consulting a wound ostomy continence nurse for incontinent diversions and monitoring the stoma and peristomal skin for breakdown.

Factors Affecting Urinary Elimination

• Poor abdominal and pelvic muscle tone, acute and chronic disorders, and spinal cord injuries are factors.

Age-Related Factors

• Full bladder control is typically achieved by 4 to 5 years.
• Prostate enlargement in older males can obstruct the bladder outlet, causing urinary retention, urgency, incontinence, and UTIs.
• Childbirth and gravity weaken the pelvic floor, increasing the risk of bladder prolapse and stress incontinence.
• Kegel exercises can help manage stress incontinence.
• Post-menopausal clients may experience decreased perineal tone due to reduced estrogen levels, leading to urgency, stress incontinence, and UTIs.

Older Adult Considerations

• Older adults have fewer nephrons, decreased bladder muscle tone (leading to frequency), inefficient bladder emptying (increasing UTI risk), increased nocturia, chronic illnesses, and mobility/dexterity issues.

Pregnancy-Related Factors

• A growing fetus compromises bladder space
• 30-50% increase in circulatory volume increases renal workload and output.
• Relaxin hormone causes sphincter relaxation

Diet, Immobility, and Psychosocial Factors

• Increased sodium intake decreases urination, caffeine and alcohol increase urination.
• Immobility-related incontinence occurs due to difficulty accessing the bathroom.
• Emotional stress, anxiety, public toilets, lack of privacy during hospital stays, and timed bathroom breaks in schools are psychosocial factors.

Pain and Surgical Procedures

• Pain can suppress the urge to urinate.
• Ureteral obstruction can lead to renal colic, and arthritis or painful joints can cause immobility and delayed urination.
• Surgical procedures with anesthesia and opioid analgesics can alter glomerular filtration rate, decreasing urine output; lower abdominal surgery can cause obstructive edema and inflammation.

Medications Affecting Urinary Elimination

• Diuretics prevent water reabsorption.
• Antihistamines and anticholinergics can cause urinary retention.
• Chemotherapy can be toxic to the kidneys.
• Medications can also change urine color: Phenazopyridine (orange/red), Amitriptyline (green-blue), Levodopa (dark), and Riboflavin (bright yellow).

Urinary Tract Infections (UTIs)

• UTIs may be caused by female anatomy (close urethral meatus and anus proximity) and indwelling urinary catheters.
• Manifestations include urgency, frequency, fever, painful urination, flank pain, suprapubic discomfort, cloudy/foul-smelling/blood-tinged urine.
• Older adults may experience confusion, incontinence, falls, fatigue, and anorexia.

UTI Client Education

• Unless its contraindicated, drink 2000 to 3000 mL of fluid daily
• Take the complete course of prescribed antibiotics.
• Avoid tight-fitting pants and bubble baths or powders to the perineum.
• Practice proper perineal care (front to back), wear cotton undergarments, and urinate after intercourse.

Diagnostic Tests for Urinary Issues

• Bedside sonography with a bladder scanner measures bladder volume and residual volume after urination using a noninvasive portable ultrasound.
• Kidneys, ureters, bladder X-ray determines size, shape, and position.
• Intravenous pyelogram involves injecting contrast media (iodine) for visualizing ducts, renal pelvis, ureters, bladder, and urethra.
• A shellfish allergy is not always a contraindication for contrast media (iodine), further assessment may be needed.
• Renal scan views renal blood flow and anatomy without contrast.
• Renal ultrasound views gross renal structures and abnormalities with high-frequency sound waves.
• Cystoscopy uses a lighted instrument to visualize, treat, and obtain specimens.
• Urodynamic testing assesses bladder muscle function by filling the bladder with CO2 or 0.9% sodium chloride and comparing pressure readings.

Promoting Healthy Urinary Elimination

• Use urinal for males, toilet, bedpan, or commode (fracture pan for supine clients or those in body/leg casts; regular pan for clients who can sit up).
• Procedure nursing actions involve ensuring clients sit when possible and providing privacy and adequate time.
• To accurately record intake and output, use a hard plastic urometer on an indwelling catheter drainage bag
• Use Graduated cylinders, urinal, or toilet receptacle
• Measure output from bedpan, commode, or collection bag into a graduated container
• Use a receptacle to measure urine clients void into the toilet.
• Use markings on the side of the urinal to measure urine.
• Inadequate output (less than 30 mL/hr for more than 2 hours) must be reported

Specimen Collection

• Equipment includes a specimen container (non-sterile for urinalysis, sterile for clean-catch midstream/catheter specimens), soap/cleansing solution, towel, gloves, specimen label, and urine collection container (catheter, urinal, receptacle in toilet/commode).
• Urinalysis is a random, non-sterile specimen.
• Nursing actions include explaining the procedure and labeling the container per facility policy.
• Clean-catch midstream for culture and sensitivity (C&S) should involve teaching the client the technique and collecting midstream after cleansing the urethral meatus.
• Catheter urine specimens for C&S require a sterile specimen from a straight or indwelling catheter using surgical asepsis.
• Timed urine specimens require collection for 24 hours (or other duration), discarding the first void, and collecting all other urine, refrigerating, labeling, and transporting.

Catheter Insertion

• The usual catheter equipment includes a usual size and type of catheter (8-10 Fr for children, 10-12 Fr for females, 12-14 Fr for males).
• Use silicon or Teflon products for its use when clients have latex allergies.
• A catheterization kit includes sterile drainage bag for indwelling catheter insertion
• Other materials include Soap and water and Collection container for straight catheterization
• Provide privacy, explain the procedure, and use sterile technique for insertion.

Catheter Care

• Closed intermittent irrigation maintains patency or removes blockages from indwelling catheters using sterile technique.
• Routine catheter care involves cleaning with soap and water at the insertion site
• Cleanse the catheter at least three times a day and after defecation.
• Monitor for patency and check the tubing for kinks/sediment. And ensure the collection bag is below the bladder to avoid reflux.

Condom Catheter Application

• Gloves, condoms, elastic tape, Leg or standard collection bag are the typical equipment.
• Procedure nursing actions involve explaining the procedure with the correct technique for application.

Catheter-Associated Urinary Tract Infection (CAUTI)

• CAUTIs occur while an indwelling catheter is in place or up to 48 hours after discontinuation.
• Risk factors are the use of indwelling urinary catheters, increased dwell time, opening the closed drainage system, routine changing, and irrigation.
• Manifestations are Urinary frequency, urgency, nocturia, flank pain, hematuria, cloudy, foul-smelling urine, and fever.
• Older adults can have New onset of increased confusion, falls, incontinence, anorexia, fever, tachycardia, hypotension.
• Prevent CAUTIs by using aseptic technique, preventing obstruction/backflow, keeping the drainage bag below the bladder, providing perineal hygiene, assessing the need for the catheter daily, keeping the system sterile/closed, and draining the bag when half full.

Urinary Incontinence

• Increases risk of skin breakdown and falls, especially in older adults.

Types of Urinary Incontinence

• Stress incontinence: small urine loss with increased abdominal pressure (laughing, sneezing, lifting) due to weak pelvic floor muscles (childbirth/menopause in females, prostatectomy in males).
• Urge incontinence: inability to reach the bathroom in time due to overactive detrusor muscle often related to UTI or overactive bladder.
• Overflow incontinence: frequent loss of small amounts of urine due to urinary retention from bladder overdistention, obstruction, or impaired detrusor muscle; may result from neurologic disorders or enlarged prostate.
• Reflex incontinence: involuntary moderate urine loss without warning due to hyperreflexia of the detrusor muscle; usually from spinal cord dysfunction.
• Functional incontinence: urine loss due to factors interfering with responding to the need to urinate (cognitive, mobility, environmental barriers).
• Transient incontinence: reversible incontinence due to inflammation/irritation (UTI), cognitive impairment, disease processes (hyperglycemia), medications (diuretics, anticholinergics, sedatives).

Assessment and Data Collection for Incontinence

• Risk factors include female anatomy, multiple pregnancies/vaginal births, aging, chronic urinary retention, urinary bladder spasm, renal disease, neurologic disorders, medication therapy, obesity, confusion/dementia/immobility/depression, physiological changes of aging, and decreased estrogen/pelvic-muscle tone. Expected findings include urine loss (laughing, coughing, sneezing), enuresis, bladder spasms, urinary retention, frequency, urgency, and nocturia.
• Laboratory Tests: Urinalysis and urine culture and sensitivity: To identify UTI (presence of RBCs, WBCs, micro-organisms)
• Abnormal diagnostic procedures may be detected include: Ultrasound, Voiding cystourethrography, Cystourethroscopy, Uroflowmetry or Electromyography

Nursing Care for Incontinence

• Establishing a toileting schedule, monitoring/increasing daytime fluid intake, decreasing evening fluid intake, removing barriers to toileting, providing incontinence garments, using external/condom catheters, avoiding indwelling catheters, and providing incontinence care are important.

Client Education for Incontinence

• Maintaining bowel movements, emptying the bladder, keeping an incontinence diary, performing Kegel exercises, bladder compression techniques (Credé, Valsalva, double voiding, splinting), avoiding caffeine/alcohol, understanding medication effects, and vaginal cone therapy can help.

Bladder-Retraining Program

• Increases the bladder's ability to hold urine and clients' ability to suppress urination.
• Nursing actions: use timed voiding to increase intervals between urination, assist clients to perform relaxation techniques, offer incontinence undergarments while clients are retraining, and Provide positive reinforcement as clients remain continent.
• In their education : Urinate at scheduled intervals, working toward the optimal 4-hr intervals, Hold urine until the scheduled toileting time, keep track of urination times & perform pelvic floor (Kegel) exercises

Urinary Habit Training

• Helps clients with limited cognitive ability to establish a predictable pattern of bladder emptying.
• Client education should involve Clients should know to : Urinate at scheduled intervals & Follow a toileting schedule according to the pattern with which they have no incontinence.

Intermittent Urinary Catheterization

• It reduces the risk of infection from indwelling catheterization, which is a temporary intervention for clients at risk for skin breakdown, or when other options have failed. .
• This involes adjusting frequency of catheterization to keep output at 400 mL or less.
• and to Explain the procedure.

Suprapubic Catheter

• This catheter invloves surgeons inserting suprapubic catheters into the abdomen above the pubic bone and in the bladder then suture the catheter in place.
• Catheters (suprapubic or urinary) remain until clients have a post-void residual of less than 50 mL.

Care and Management of Catheters

• Monitor output and for any manifestations of infection
• Keep catheters patently at all times
• Determine clients' ability to detect the urge to urinate.
• Provide the Perform skin care around the insertion site
• Clients should Drink 2 to 3 L of fluid daily, avoid colas, coffee, tea, alcohol, and chocolate because these can irritate the bladder.

Skin Breakdown from Chronic Exposure to Urine

• Monitor for breakdown
• Apply protective barrier creams & Implement a bladder-retraining program.

Social Isolation

• Encourage clients to express their emotions and remind them that support is availble.
• Assist with measures to conceal urinary leaking (perineal pads, external catheters, adult incontinence garments).

Medications for Urinary Issues

• Antibiotics (Gentamicin, cephalexin, trimethoprim/sulfamethoxazole, ciprofloxacin) treat UTIs; Administer medication with food to decrease gastrointestinal distress.
• Tricyclic antidepressants (Nortriptyline) have anticholinergic effects that relieve urinary incontinence; monitor for dizziness/orthostatic hypotension, and do not administer with MAOIs.
• Urinary antispasmodics/anticholinergic agents (Oxybutynin and dicyclomine) decrease urgency and pain from neurogenic/overactive bladders; check glaucoma history and monitor for dizziness/tachycardia/urinary retention.
• Phenazopyridine treats UTI manifestations, but not the infection itself; and causes urine to turn orange.
• Hormone replacement therapy increases blood supply to the pelvis.