Urinary Elimination Summary Notes (2).docx

Urinary Elimination The urinary system consists of kidneys and ureters, bladder, and urethra. The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of...

Urinary Elimination The urinary system consists of kidneys and ureters, bladder, and urethra. The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver. Adequate elimination depends on the coordinated function of the kidneys, ureters, bladder, and urethra. The kidneys filter waste products of metabolism from the blood. The ureters transport urine from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra. Bladder serves as a temporary reservoir for urine. Sphincter guards opening between urinary bladder and urethra. Male urethra functions in excretory and reproductive systems. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area. Urinary elimination is a basic human function that can be compromised by a wide variety of illnesses and conditions. It is the nurse’s role to assess urinary tract function and support bladder emptying. Act of Urination Urination, micturition, and voiding are all terms that describe the process of bladder emptying. Micturition is a complex interaction between the bladder, urinary sphincter, and central nervous system. Variables including frequency and factors affecting urination are developmental considerations, food and fluid intake, psychological variables, activity and muscle tone, pathologic conditions, and medications. Children cannot voluntarily control voiding until 18 to 24 months. Readiness for toilet training includes the ability to: recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and communicate the sense of urgency. Older adults may experience a decrease in bladder capacity and are at increased risk for urinary incontinence due to chronic illnesses and factors that interfere with mobility, cognition, and manual dexterity. Social expectations (e.g., school recesses, work breaks) can interfere with timely voiding. Anxiety and stress sometimes affect a sense of urgency and increase the frequency of voiding. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. Depression can decrease the desire for urinary continence. The need for privacy and adequate time to void can influence the ability to adequately empty the bladder. If fluids, electrolytes, and solutes are balanced, increased fluid intake increases urine production. Alcohol decreases the release of antidiuretic hormones, thus increasing urine production. Fluids containing caffeine and other bladder irritants can prompt unsolicited bladder contractions resulting in frequency, urgency, and incontinence. Diabetes mellitus, multiple sclerosis, and stoke can alter bladder contractility in addition to the ability to sense bladder filling. Patients will experience either bladder overactivity or deficient bladder emptying. Arthritis, Parkinson’s disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet. Spinal cord injury or intervertebral disk disease (above S-1) can cause the loss of urine control due to bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter. Prostatic enlargement (e.g., benign prostatic hyperplasia or BPH) can cause obstruction of the bladder outlet causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow requiring temporary use of an indwelling urinary catheter. Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness causing urinary retention. Diuretics increase urinary output by preventing reabsorption of water and certain electrolytes. Common Urine Elimination Problems The most common urinary elimination problems involve the inability to store urine or to fully empty urine from the bladder. Problems can result from infection, irritable or overactive bladder, obstruction of urine flow, impaired bladder contractility, or issues that impair innervation to the bladder resulting in sensory or motor dysfunction. Patients may have no urine output over several hours, and in some cases will experience frequency, urgency, small volume voiding or incontinence of small volumes of urine. Postvoid residual (PVR) is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization. Incontinence caused by urinary retention is called overflow incontinence or incontinence associated with chronic retention of urine. The pressure in the bladder exceeds the ability of the sphincter to prevent the passage of urine and the patient will dribble urine. Urinary tract infections (UTIs) are usually caused by Escherichia coli. Urinary tract infections are characterized by location; upper urinary tract (kidney) or lower urinary tract (bladder, urethra) and have signs and symptoms of infection. Symptoms of a lower urinary tract infection (bladder) can include burning or pain with urination (dysuria), irritation or inflammation of the bladder (cystitis) characterized by urgency, frequency, incontinence, suprapubic tenderness, and foul-smelling cloudy urine. Catheter-associated UTIs (CAUTIs) are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs. Urinary retention is an accumulation of urine due to the inability of the bladder to empty and the patient is voiding frequently without emptying the bladder. When that occurs, the health care provider may order catherization. Urinary incontinence (UI) UI is involuntary leakage of urine. Common forms of UI are: Stress incontinence. Involuntary loss of urine associated with pressure exerted on the bladder by coughing, sneezing, laughing, exercising or lifting something heavy. Urge incontinence. Sudden, intense urge to urinate followed by an involuntary loss of urine. Overactive bladder is defined as urinary urgency, often accompanied by increased urinary frequency and nocturia that may or may not be associated with urgency incontinence and is present without obvious bladder pathology or infection. Overflow incontinence. Frequent or constant dribbling of urine due to a bladder that doesn't empty completely (chronic retention of urine) as in patients with BPH. Functional incontinence. Caused by factors that prohibit or interfere with a patient’s access to the toilet or other acceptable receptacle for urine. In most cases, there is no bladder pathology. It is a significant problem for older adults who experience problems with mobility or the dexterity to manage their clothing and toileting behaviors. Mixed incontinence. Describes incontinence that has multiple interacting risk factors. Most often this refers to a combination of stress incontinence and urge incontinence. Reflex: emptying of the bladder without sensation of need to void as in neurogenic bladder dysfunction due to spinal cord injury Total: continuous, unpredictable loss of urine Urinary Diversion Patients who have had the bladder removed (cystectomy) due to cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI, require surgical procedures that divert urine to the outside of the body through an opening in the abdominal wall called a stoma. Urinary diversions are constructed from a section of intestine to create a storage reservoir or conduit for urine. Diversions can be temporary or permanent, continent or incontinent. The patient with an incontinent urinary diversion must wear a pouch to collect the effluent (drainage). The pouch will keep the patient clean and dry, protect the skin from damage and provide a barrier against odor. The pouch should be changed every 4 to 6 days. Each pouch may be connected to a bedside drainage bag for use at night. When changing a pouch, gently cleanse the skin surrounding the stoma with warm tap water using a washcloth and pat dry. Measure the stoma and cut the opening in the pouch. Then apply the pouch after removing the protective backing from the adhesive surface. Press firmly into place over the stoma. Observe the appearance of the stoma and surrounding skin. The stoma is normally red and moist and is located in the right lower quadrant of the abdomen. It is important for the patient to have the correct type and fit of an ostomy pouch so that the pouch fits snugly against the skin’s surface around the stoma preventing damaging leakage of urine. Patients with continent urinary diversions do not have to wear an external pouch. However, if the patient has a continent urinary reservoir, the patient must be taught how to intermittently catheterize the pouch. Nephrostomy tubes are small tubes that are tunneled through the skin into the renal pelvis. These tubes are placed to drain the renal pelvis when the ureter is obstructed. Patients do go home with these tubes and need careful teaching about site care and signs of infection. The urinary tract is sterile. The use of infection control principles will help to prevent the spread of UTI. Perineal care or examination of the genitalia requires medical asepsis, including proper hand hygiene. Any invasive procedure such as catheterization requires sterile technique. Assessment During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that patient-centered clinical decisions required for safe nursing care are made. Throughout the nursing assessment, it is important for the nurse to consider the patient’s frame of reference related to their illness or urinary problem. The health history includes a review of the patient’s elimination patterns, symptoms of urinary alterations, and assessment of factors that are affecting the ability to urinate normally. A physical examination provides you with data to determine the presence and severity of urinary elimination problems. The primary areas to assess include the kidneys, bladder, external genitalia, urethral meatus, and perineal skin. Fluid intake and the pattern and amounts, which are objective data, are important to assess. Conduct a physical examination of the urinary system, skin hydration, and urine; and correlate these findings with procedures and diagnostic tests. Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment. Urinary bladder: Palpate and percuss the bladder or use a bedside scanner. Urethral orifice: Inspect for signs of infection, discharge, or odor. Skin: Assess for color, texture, turgor, and excretion of wastes. Urine: Assess for color, odor, clarity, and sediment. Normal fresh urine is transparent and has an aromatic odor. As urine stands, it often develops an ammonia odor because of bacterial action. Normal urine color ranges from pale yellow to deep amber. Bleeding from the kidneys or ureters usually causes urine to become dark red; bleeding from the bladder or urethra usually causes bright red urine. Various medications and foods change the urine’s color. Dark amber urine is the result of high concentrations of bilirubin (urobilinogen) in patients with liver disease. Report unexpected color changes to the health care provider. Urine that stands several minutes in a container becomes cloudy. In patients with renal disease, freshly voided urine appears cloudy because of protein concentration. Urine may also appear thick and cloudy as a result of bacteria and white blood cells (WBCs). Urine has a characteristic ammonia odor. The more concentrated the urine, the stronger the odor. As urine remains standing (e.g., in a collection device), more ammonia breakdown occurs, and the odor becomes stronger. A foul odor may indicate a UTI. Some foods, such as asparagus and garlic, can change the odor of urine. The assessment of urine includes measuring the patient’s fluid intake and urinary output (I&O) and observing the characteristics of the urine. Intake measurements need to include all oral liquids and semi-liquids, enteral feedings, and any parenteral fluids. Output measurement includes not only urine but any fluid that leaves the body that can be measured, such as vomitus, gastric drainage tubes, and wound drains. A change in urine volume can be a significant indicator of fluid imbalance, kidney dysfunction, or decreased blood volume. After a patient voids in a bedside commode, bedpan, or urinal, or when urine is emptied from a catheter drainage bag, urine can be measured using a graduated measuring container. For patients who void in a toilet, a urine hat will collect urine, allowing for patient privacy in the bathroom. Catheterized patients may have a specialized drainage bag with an urometer attached between the drainage tubing and drainage bag that allows for accurate hourly urine measurement. As body fluid, gloves should always be worn while disposing urine. Nursing Diagnosis Collected data about urinary functioning may lead to one or more nursing diagnoses. Identify urinary problems amenable to nursing therapy. Applicable diagnoses include: Functional urinary incontinence Stress urinary incontinence Urge urinary incontinence Risk for infection Toileting self-care deficit Impaired skin integrity Impaired urinary elimination Urinary retention Recall that an important part of formulating nursing diagnoses is identifying the relevant causative or related factor. This is followed by choosing interventions that treat or modify the related factor for the diagnosis to be resolved. Specifying related factors for each diagnosis allows selection of individualized nursing interventions. Identification of the defining characteristics leads to the selection of an appropriate NANDA International nursing diagnostic label. For example, toileting self-care deficit related to impaired transfer ability or impaired mobility status guides the selection of nursing interventions that remove barriers to toilet access. Goals: Produce sufficient quantity of urine to maintain fluid, electrolyte, and acid–base balance. Empty bladder completely at regular intervals without discomfort. Provide care for urinary diversion and know when to notify physician. Develop plan to modify factors contributing to current or future urinary problems. Correct unhealthy urinary habits. Interventions and Implementation Note that trauma or illness may result in the patient’s need for nursing assistance with voiding and that nursing interventions that facilitate use of the toilet, bedpan, urinal, and commode; perform catheterizations; and assist with urinary diversions should support planned patient goals. Laboratory and Diagnostic Testing Nurses are often responsible for collecting urine specimens for laboratory testing. The type of test determines the method of collection. Label all specimens with the patient’s name, date, time, and type of collection. Most urine specimens need to reach the laboratory within 2 hours of collection or must be preserved according to laboratory protocol. Urine that stands in a container at room temperature without the required preservative will grow bacteria and may experience changes that will affect the accuracy of the test. Urine Specimens Routine urinalysis Clean-catch or midstream specimens Sterile specimens from indwelling catheter 24-hour urine specimen Promote normal urination by maintaining normal voiding habits, promoting fluid intake, strengthening muscle tone, and stimulating urination and resolving urinary retention. Maintain normal voiding habits through: Schedule Urge to void Privacy Position Hygiene Complete independent and collaborative interventions to help the patient achieve the desired outcomes and goals. Note 4P’s (pain, position, potty, possessions) of purposeful hourly rounding. Create as much privacy as possible by closing the door and bedside curtain; asking visitors to leave a room when a bedside commode, bedpan, or urinal is used; and masking the sounds of voiding with running water. Respond to requests for assistance with toileting as quickly as possible. UTI can be prevented by promoting adequate fluid intake, perineal hygiene, and voiding at regular intervals. Adequate fluid intake will help flush out solutes or particles that collect in the urinary system and decrease bladder irritability. To prevent nocturia, suggest that the patient avoid drinking fluids 2 hours before bedtime. A strategy to promote relaxation and stimulate bladder contractions is to help patients assume the normal position for voiding. In the presence of high postvoid residuals or a complete inability of the bladder to empty, urinary catheterization, either intermittent or indwelling, is needed. Catheterization Urinary catheterization is the placement of a tube through the urethra into the bladder to drain urine. This is an invasive procedure that requires a medical order and aseptic technique. Note various types of catheters for straight, indwelling urethral, intermittent, suprapubic, or 3 way Foley catheter for internal and external forms of catheterization. Reasons for Urinary catheterization Relieving urinary retention Prolonged patient immobilization Obtaining a sterile urine specimen when patient is unable to void voluntarily Accurate measurement of urinary output in critically ill patients Assisting in healing open sacral or perineal wounds in incontinent patients Emptying the bladder before, during, or after select surgical procedures and before certain diagnostic examinations. Providing improved comfort for end-of-life care Urinary catheters are made with one to three lumens. Single-lumen catheters are used for intermittent/straight catheterization (i.e., the insertion of a catheter for one-time bladder emptying). Double-lumen catheters, designed for indwelling catheters, provide one lumen for urinary drainage while a second lumen is used to inflate a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation or when it becomes necessary to instill medications into the bladder. One lumen drains the bladder, a second lumen is used to inflate the balloon, and a third lumen delivers irrigation fluid into the bladder. The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the catheter. Most adults with an indwelling catheter use a size 14 to16 Fr to minimize trauma and risk for infection. Indwelling catheters come in a variety of balloon sizes from 3 mL (for a child) to 30 mL for continuous bladder irrigation (CBI). The size of the balloon is usually printed on the catheter port. The recommended balloon size for an adult is a 10-mL balloon (the balloon is 5 mL and requires 10 mL to fill completely). During catheterization, the catheter is advanced further in after urine appears before inflating the balloon to avoid urethral trauma. In patients with indwelling catheters, specimens are collected without opening the drainage system using a special port in the tubing. Always hang the bag below the level of the bladder on the bed frame or a chair so that urine will drain down, out of the bladder. The bag should never touch the floor. When a patient ambulates, carry the bag below the level of the patient’s bladder. Ambulatory patients may use a leg bag. Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, or routine Foley catheter care to reduce the risk for CAUTI. Empty drainage bags when half full. An overfull drainage bag can create tension and pull on the catheter resulting in trauma to the urethra and/or urinary meatus and increasing the risk for CAUTI. Expect continuous drainage of urine into the drainage bag. In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter. A key intervention to prevent infection is maintaining a closed urinary drainage system as well as prevention of urine back flow from the tubing and bag into the bladder. To maintain the patency of indwelling urinary catheters, it is sometimes necessary to irrigate or flush a catheter with sterile solution. There are two types of irrigation: closed catheter irrigation and open irrigation. Closed catheter irrigation provides intermittent or continuous irrigation of the urinary catheter without disrupting the sterile connection between the catheter and the drainage system. Continuous bladder irrigation (CBI) is an example of a continuous infusion of a sterile solution into the bladder, usually using a three-way irrigation closed system with a triple-lumen catheter. CBI is frequently used following genitourinary surgery to keep the bladder clear and free of blood clots or sediment. Prompt removal of an indwelling catheter after no longer needed followed by perineal care is a key intervention that has proven to decrease the incidence and prevalence of infection. Patients are monitored for both timing of voiding after catheter is removed and quantity voided. To avoid the risks associated with urethral catheters, two available alternatives are suprapubic and condom catheters. A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The external catheter, also called a condom catheter or Texas catheter, is a soft, pliable condom-like sheath that fits over the penis providing a safe and noninvasive way to contain urine.