Urinary Elimination PDF

Urinary Elimination Dr. Ghonem Elsayed Ghonem DR. ESRAA HASSAN IBRAHIM Faculty of Nursing-Suez Canal University  At the end of the lecture the student will be able to: 1. Describe the process of urination, from urine formation through micturition....

Urinary Elimination Dr. Ghonem Elsayed Ghonem DR. ESRAA HASSAN IBRAHIM Faculty of Nursing-Suez Canal University  At the end of the lecture the student will be able to: 1. Describe the process of urination, from urine formation through micturition. 2. Identify factors that influence urinary elimination. Learning 3. Identify common causes of selected urinary objectives problems. 4. Describe nursing assessment of urinary function, including subjective and objective data. 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence Introduction The body removes from food and fluids the nutrients necessary for essential bodily functions, such as physical activity, self-repair, and mental operations. Waste products are left in the blood and in the bowel. The organs of the urinary system help to excrete wastes and maintain a balance of chemicals and water in the body  Anatomy of urinary system Kidneys Ureters Bladder Urethra  Anatomy of urinary system The paired kidneys : situated on either side of the spinal column, The right kidney is slightly lower than the left due to the position of the liver. The functional units of the kidneys, the nephrons.  Anatomy of Urinary system Ureters The upper end of each ureter enters the kidney. The lower ends of the ureter enters the bladder. In adults the ureters are from 25 to 30 cm Urethra: The urethra extends from the bladder to the urinary meatus (opening) The female urethra is between 3 and 4 cm but male urethra is approximately 20 cm. Pelvic Floor: The vagina, urethra, and rectum pass through the pelvic floor, which consists of sheets of muscles and ligaments provide support to the viscera of the pelvis e urethra serves only as a passageway for the elimination of urine  Physiology of kidneys Primary functions: The filter metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine. The kidneys also help to regulate blood volume, blood pressure, electrolyte levels, and acid–base balance by selectively reabsorbing water and other substances. Secondary functions: produce erythropoietin, secrete the enzyme renin, and activate vitamin D3 (calcitriol). Formation of urine 1. Glomerular filtration Blood pressure forces plasma, dissolved substances, and small proteins out of the porous glomeruli into Bowman’s capsule to form a liquid called filtrate The glomerular filtration rate is the amount of filtrate formed by the kidneys per minute  Cont., Formation of urine 2. Tubular Reabsorption As the filtrate journeys through the tubule, 99% is reabsorbed into the peritubular capillaries. 1% form urine Antidiuretic hormone (ADH( and aldosterone thus have the effect of maintaining normal blood volume and blood pressure  How does urinary elimination occur? When the bladder triggering The stretch contains 200 to motor impulses receptors send 450 mL of urine that cause the sensory (50 to 200 mL in detrusor muscle children), the impulses to the to contract and Voiding voiding reflex distention the internal center in the activates stretch sphincter to spinal cord receptors in the relax. bladder wall. WHAT FACTORS AFFECT URINARY ELIMINATION? 1. Developmental Factors 2. Personal, Sociocultural, and Environmental Factors 3. Nutrition, Hydration, and Activity Level 4. Medications 5. Pathological Conditions 6. Surgery and Anesthesia  Developmental Factors Newborns Do not concentrate urine well void up to 25 times during the first 24 hours of life. The normal specific gravity of their urine is 1.008 Old age The size and functioning of the kidneys begin to decrease at about age 50, by age 80 only about two-thirds of the functioning nephrons remain. This results in a decline in filtration rate, which affects the ability to dilute and concentrate urine  Personal, Sociocultural, and Environmental Factors Delaying urination promotes urinary stasis and can lead to bladder infections situations can inhibit voiding: Busy Anxiety Lack of Time Lack of Privacy  Drinks that contain caffeine, such as coffee, tea, cola, and chocolate, act as diuretics and increase urine production. Nutrition, Consuming large amounts of alcohol impairs the release of ADH, resulting in increased production of urine. Hydration, and In contrast, a diet high in salt causes water retention and Activity Level decreases urine production. During prolonged periods of physical activity, especially in hot weather, the body loses sodium and other electrolytes rapidly through sweat  Medications Phenazopyridine hydrochloride (Pyridium) a bladder analgesic, turns the urine a deep orange-red color. Diuretics, treat blood pressure, fluid retention, and edema by increasing elimination of urine. Other medications are nephrotoxic (damaging to the kidneys).  Surgery and Anesthesia Reproductive and Urinary Tract Surgeries Manipulation of the urinary tract frequently leads to trauma, bleeding, or the introduction of bacteria into a normally sterile tract. Surgery in the Pubic Area, Vagina, or Rectum is associated with a high incidence of trauma to the urinary organs, lower abdominal swelling, loss of pelvic muscle control Anesthetic Agents can decrease blood pressure and glomerular filtration, thus decreasing urine formation. Spinal anesthesia decreases the patient’s awareness of the need to void, which may lead to bladder distention.  Pathological Conditions Infection or inflammation of the bladder, ureters, or kidneys Renal calculi (kidney stones) or tumors, which obstruct the normal flow of urine In older men, hypertrophy of the prostate gland due to benign or cancerous lesions, which interferes with flow of urine from the bladder into the urethra Diseases involving other systems can indirectly affect urinary function. Cardiovascular decrease blood flow through the glomeruli Nervous system: conditions that affect control of the urinary system organs will impair urinary elimination. Systemic infection especially when accompanied by a high fever, causes the kidneys to reabsorb and retain water. Immobility and impaired communication may interfere with the ability to get to the bathroom in time  Common urinary alterations 1. Urinary Tract Infections 2. Urinary retention 3. Urinary Incontinence  Urinary Tract Infections Urethritis An infection limited to the urethra Cystitis: occurs when bacteria travel up the urethra into the bladder, causing a bladder infection. Pyelonephritis: not treated promptly, the infection may progress superiorly (upward) to the ureters or kidneys (pyelonephritis). Physiologic barriers of infection for the urinary system One-way valves at the junction of the ureters and bladder help prevent urine From backing up toward the kidneys. The flow of urine during urination helps wash bacteria out of the body. The prostate gland produces secretions that slow bacterial growth  Females: Sexually active women. During sexual activity, perineal pathogens may enter the urethra. Pregnant women compress bladder changes in bacterial flora the use of spermicides that may alter vaginal pH and thus affect its flora engagement with a new sexual partner within the last year masturbation Males: masturbation Men with an enlarged prostate. resulting in stagnant urine, which provides an excellent medium for the growth of bacteria. Risk Factors for UTI People with kidney stones. Kidney stones (renal calculi) obstruct the flow of urine, creating stagnation, and irritate the urinary tract  Risk Factors for Urinary Tract Infection Indwelling catheter: Failing to maintain a closed drainage system increases the risk for infection by allowing bacteria to enter the catheter The catheter irritates the mucosal lining of the urethra, creates a portal of entry for microbes. The longer the catheter is indwelling, the higher is the risk of developing UTI Immunocompromised patients: People who have diabetes mellitus. Glucose in the urine provides nutrients for bacteria to multiply.  Term Definition Anuria The absence of urine production, or a urinary output < 100 mL/day (< 30 mL/hour) Dribbling Dribbling of urine from the urethra despite voluntary control of micturition. It may be at the end of micturition or continuous Dysuria Pain and burning on micturition, usually as a result of an infection or obstruction Frequency Voiding at frequent intervals, i.e. < 2-hourly Haematuria The presence of blood in the urine Hesitancy Difficulty starting micturition Incontinence The inability to control the passage of urine Nocturia Excessive or frequent urination at night Oliguria A decreased urine production resulting in an output < 500 mL/day Polyuria The excretion of an abnormally large volume of urine Retention The accumulation of urine in the bladder as a result of being unable to fully empty the bladder Residual urine The volume of urine remaining after voiding Urgency The feeling of needing to void immediately  Urinary retention Is an inability to empty the bladder completely. Etiologies: Obstruction: Enlarged prostate Stones lodged Strictures or scars from previous injury Tumors or blood clots in the urinary system Inflammation and swelling: Swelling narrows the diameter of the urethra so that urine cannot flow freely. Infection or surgery in the pelvic region  Neurological Problems: Cont., Urinary retention spinal cord tumors or injury herniated disk etiology viral infections involving perineal nerves (e.g., genital herpes) Medications: Anesthesia and other medications can also cause temporary problems with urination. Anxiety: Painful urination may produce anxiety and lead to voluntary withholding of urination  Urinary Incontinence Urinary incontinence (UI) is a lack of voluntary control over urination. Types of Urinary Incontinence Transient incontinence A sudden onset Usually reversible signs and symptoms Causes: Urinary tract infection and medications, especially diuretics. Established urinary incontinences (chronic or persistent incontinence) Types of Urinary Incontinence Urge incontinence: Is the involuntary loss of larger amounts of urine accompanied by a strong urge to void. Stress incontinence: Is an involuntary loss of small amounts of urine with activities that increase intraabdominal pressure. Activities that produce leakage of urine also include exercise, laughing, sneezing, coughing, and lifting. Mixed incontinence: Is a combination of urge and stress incontinence Overflow incontinence: Is the loss of urine in combination with a distended bladder. functional incontinence: No urinary or neurological cause is involved Inability of a usually continent person to reach the toilet in time to avoid unintentional loss of urine Reflex incontinence: Is loss of urine when the person does not realize the bladder is full and has no urge to void. Enuresis: Is involuntary urination after about 5 to 6 years of age, when control is usually established. Nocturnal enuresis (bedwetting): can persist until age 10 or later.  NURSING MANAGEMENT (Nursing Process) 1. Assessment Nursing History Physical Examination Diagnostic Studies 2. Nursing activities for promoting normal urination 3. Prevention of urinary tract infection 4. Managing urinary retention  A complete assessment of a client’s urinary function includes the following: 1. Nursing history 2. Physical assessment of the genitourinary system, hydration ASSESSMENT status, and examination of the urine 3. Relating the data obtained to the results of any diagnostic tests and procedures  Nursing history 1. The nurse determines the client’s normal voiding pattern and frequency 2. appearance of the urine and any recent changes 3. any past or current problems with urination 4. the presence of an urostomy 5. factors influencing the elimination pattern  Physical assessment percussion of the kidneys to detect areas of tenderness. Palpation and percussion of the bladder are also performed. Assess patient skin Because problems with urination can affect the elimination of wastes from the body, it is important for the nurse to assess the skin for color, texture, and tissue turgor as well as the presence of edema. If incontinence, dribbling, or dysuria is noted in the history, the skin of the perineum should be inspected for irritation because contact with urine can excoriate the skin.  Diagnostic test Urea, the end product of protein metabolism, is measured as blood urea nitrogen (BUN). Creatinine is produced in relatively constant quantities by the muscles. Evaluate renal function. The creatinine clearance test uses 24- hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function.  Diagnostic test Urinalysis: Collecting urine specimens, measuring specific gravity Urine culture: to determine the type of bacteria in your urine. Ultrasound: In this test, sound waves create an image of the internal organs. Cystoscopy: This test uses a special instrument fitted with a lens and a light source (cystoscope) to see inside the bladder from the urethra. CT scan: imaging test, a CT scan is a type of X-ray that takes cross sections of the body (like slices). Characteristic Normal Abnormal Nursing Considerations Output of less than 30 mL/h may indicate decreased Amount in 24 1,200–1,500 Under 1,200 blood flow to the kidneys and should be immediately hours adult mL mL reported. Concentrated urine is darker in color. Dark amber Dilute urine may appear almost clear, or very pale Cloudy Dark yellow. Straw, amber orange Red or Some foods and drugs may color urine. Color, clarity Transparent dark brown Red blood cells in the urine (hematuria) may be Mucous plugs, evident as pink, bright red, or rusty brown urine. viscid, thick White blood cells, bacteria, pus, or contaminants such as prostatic fluid, sperm, or vaginal drainage may cause cloudy urine infected urine can have a fetid odor Odor Mild smell Offensive urine high in glucose has a sweet odor. No Microorganism microorganis Urine specimens, however, may be contaminated by Sterility s present ms present bacteria from the perineum during collection. Characteristic Normal Abnormal Nursing Considerations Freshly voided urine is normally somewhat acidic. Over 8 Under 4.5 pH 4.5–8 Alkaline urine may indicate a state of alkalosis, UTI, or a diet high in fruits and vegetables. Concentrated urine has a higher specific Specific 1.010–1.025 Over 1.025 Under gravity; diluted urine has a lower specific gravity 1.010 gravity. Glucose in the urine indicates high blood glucose levels (greater than 180 mg/dL) and Glucose Not present Present may be indicative of undiagnosed or uncontrolled diabetes mellitus. Ketone bodies Blood may be present in the urine of clients Occult (microscopic) who have UTI, Blood Not present Bright red kidney disease, or bleeding from the urinary tract.  Measuring Intake and Output kidneys produce urine at a rate of approximately 50 to 60 mL per hour, Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours The normal range for 24-hour urine volume is 800 to 2,000 milliliters per day (with a normal fluid intake of about 2 liters per day). Nursing Activities for Promoting Normal Urination Provide Privacy: Provide privacy when discussing or providing care related to urination. Excuse visitors from the room draw the dividing curtains in shared room and close the door to the room. Whenever possible, give the patient time alone to void. Assist With Positioning Whenever possible, assist the patient to the bathroom to use the toilet and allow him to assume his preferred position. Provide a bedside commode or urinal for male patient and provide a bedpan for females.  nursing activities for promoting normal urination Identify your patient’s pattern, and stick to it as much as possible. Most patients void on awakening, after meals or drinking a large volume of fluid, before bedtime, or during the night for some. Promote Adequate Fluids and Nutrition Promote Adequate Fluids and Nutrition Adequate hydration promotes urinary tract function and flushes the system of waste products. provide the fluid he prefers Most people should drink at least 8 to 10 eight-ounce glasses of fluid daily perineal cleansing is an integral part of toileting hygiene Urine is irritating to the skin. perineal cleansing is an integral part of toileting hygiene Assess patient need for assistance during toileting hygiene  Prevention of Urinary Tract Infection Drink at least 8 to 10 glasses of water per day to keep urine dilute and to flush bacteria from the urinary tract. Urinate when you first feel the urge. Do not make a habit of postponing urination because bacteria can multiply in stagnant urine. Always wipe from front to back after urination or defecation. Wear cotton underwear because nylon or other synthetic fabrics prevent evaporation of moisture. Bacteria and other microorganisms grow well in a warm, moist environment. Prevention of Urinary Tract Infection Urinate after having intercourse to flush away Using soap to clean after urination and bacteria that might have chronic constipation entered the urethra. Urinate before and after sexual activity. Avoid bubble baths and This can flush bacteria out of the baking-soda baths if you have urethra and away from the bladder. a history of UTI. Clean the genitals before and after sex Promptly report any Don’t use douches, powders or sprays symptoms of UTI to your on the genitals. This can wash away healthcare provider. protective bacteria. Nursing management for patient with urinary tract infection Antibiotics are used to treat UTI. The length and type of treatment depends on the location and severity of infection. In general, a bladder infection may be treated with oral antibiotics for 1 to 5 days.  Managing Urinary Retention Clients with a mechanical obstruction to urine flow are treated by surgical removal or repair of the obstruction For clients who have loss of bladder tone: Collaborative interventions: 1. Administer cholinergic medications, which promote bladder emptying by stimulating contraction of the detrusor muscle 2. Administer alpha-adrenergic antagonists, such as tamsulosin (Flomax), which reduce urethral resistance and improve bladder emptying. 3. Use Credé’s maneuver (apply manual pressure over the bladder to promote emptying). 4. Perform urinary catheterization. Independent nursing interventions for patients with urinary retention Monitor Intake &Output Assess for risk factors for urinary retention Inspect and palpate for bladder distention. Apply heat to the lower abdomen to relax the muscles near where the bladder lies. Run water nearby, or place the patient’s hands in warm water. Cont., Independent nursing interventions for patients with urinary retention Pour distilled water over the perineum, assist the patient to take a warm sitz bath. Measure the urine that remains in the bladder immediately after the patient voids. This is known as postvoid residual urine (PVR). PVR can be measured with a portable noninvasive bladder ultrasound device (bladder scanner) or by insertion of a straight catheter  Nursing management for urinary incontinence Continence (Bladder) Retraining Bladder retraining, requires the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void. The goals are to gradually lengthen the intervals between urination to correct the client’s frequent urination, to stabilize the bladder, and to diminish urgency. Initially, voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours. To do this, the nurse instructs the client to practice deep, slow breathing until the urge diminishes or disappears. This is performed every time the client has a premature urge to void. Habit training (scheduled toileting): Attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours.  cont,., Nursing management for urinary incontinence Pelvic Floor Muscle Exercises Pelvic floor muscle (PFM), or Kegel, exercises help to strengthen pelvic floor muscles by tightening the anal sphincter as if to control the passing of gas or to hold a bowel movement. The contraction extend for 3- , 5-, or 10- second long. The pelvic muscle is relaxed after the sustained contraction. The client gradually builds up to the 10-second sustained contraction PFM can be performed anytime, anywhere, sitting or standing.