Urinary Health (slides) PDF

Physiological Need: Urinary Elimination FALL 2024 P O TT E R A N D P E R RY C H A P T E R 4 4 & R P N AO B E S T P RAC T I C E G U I D E L I N E S ( P R O M O T I N G C O N T I N E N C E ) 1 Learning Objectives 1. Discuss...

Physiological Need: Urinary Elimination FALL 2024 P O TT E R A N D P E R RY C H A P T E R 4 4 & R P N AO B E S T P RAC T I C E G U I D E L I N E S ( P R O M O T I N G C O N T I N E N C E ) 1 Learning Objectives 1. Discuss the assessment of common clinical manifestations in urinary elimination 2. Identify and discuss common factors influencing urinary elimination 3. Identify and discuss nursing diagnoses pertinent to elimination a. Urinary Incontinence b. Urinary tract infection 4. Discuss common goals and nursing interventions related to the need for elimination 2  Urinary System : Kidneys, Ureter, Bladder, Urethra Knowledge Nervous System: Sensory receptors on bladder send Base: messages to the spinal cord Physiologi which are then relayed to the cal brain Systems Muscular System: Walls of the Involved in bladder are comprised of muscle Urination Muscles and ligaments also help to hold the bladder in place 3  Knowledge Base: Urinary System FEMALE MALE Compare the length of the urethra between male and female. Which one is more susceptible for urinary tract infections? 4  Scientific Knowledge Base: Upper Urinary Tract: Kidneys (Renal Pelvis) Kidneys remove waste from the blood to form urine Nephron is the worker within the kidney Glomerulus within the nephron, allows water, glucose, amino acids, electrolytes to be filtered ◦Does not allow blood or proteins to filter ◦Glomerulus filters approx. 180L/day blood( plasma) or 115mL/minute ◦All but 1% of filtrate gets absorbed back into circulation ◦Remaining 1% becomes urine, amount of 1-2 L/day Scientific Renin- hormone that stimulates a Knowledge process called the renin-angiotensin- aldosterone system- “Tap gets turned Base: on/off” to regulate blood pressure Upper Alerts: Urinary Less than 30 ml/hour urinary Tract: output indicates problem Kidneys Protein or Blood in urine a problem (Renal Pelvis) 6 Scientific Knowledge Base: Upper Urinary Tract Ureters Tubules that connect kidneys (renal pelvis) to the bladder Move urine in wave like manner Once in the bladder, urine is not able to go back into the tubules Scientific Knowledge Base: Upper Urinary Tract: Kidneys (Renal Pelvis) Bladder Reservoir for urine until the urge to urinate develops Urethra Passage through which urine travels from the bladder, ending at the urethral meatus, through which urine exits 8 9 Central Nervous System As the bladder fills, sensors in the bladder send a message to the brain via the spinal cord. A message is sent back to start the contraction of the detrusor muscle in bladder. This leads to relaxation of the sphincter at the neck of the bladder This causes urine to be released into the urethra and voiding or micturition to occur. 10 Muscular System Several muscles are involved; bladder wall, sphincter and pelvic floor. The pelvic floor muscles keep structures anatomically correct position. 11 Process of Urination, Voiding, or Micturitio n 12  Common Alterations Nocturia: Waking at night to urinate Causative factors: age and overactive bladder Urinary retention: Urine remains in the bladder i.e., a person urinates but not all urine is releases OR a person is unable to urinate, urine stays in bladder Causes: disease or injury to the nervous system: temporary ( post childbirth), medications (including epidurals), diminished functioning of muscles involved in micturition, infection Concern: Urinary retention leads to urinary tract infection as urine stays longer in bladder, creates bladder spasms; pain and can cause kidney problems 13 Common Alterations Urinary Tract Infections Clinical manifestations: Pain, burning with urination= dysuria Fever, chills, nausea, vomiting, malaise Frequent and urgent sensation of need to void= frequency Incontinence Blood in the urine Cloudy, foul-smelling urine If upper UTI - flank pain, lower back pain, fever, chills Older person: first sign is often confusion, change in mentation 14  Urinary Tract Infections: Influencing Factors Obstruction of urinary Indwelling catheter tract Improper hygiene practices Enlarged prostate Lack of bladder emptying Sexual activity in women Older age (Box 44.2 pg. 1170) Pregnancy Certain medications Menopause- low estrogen Use of diaphragm or Long term kidney spermicidal use disease Decreased immunity 15  Refer to Table 44.1 pg. 1166 Transient- resolve once the underlying problem is resolved Urge- loss of urine right after a sudden urge to void – often with central nervous system disorders, Common multiple sclerosis, Parkinson's, and with prostate enlargement Alterations Stress incontinence-from increased intraabdominal : pressure- coughing, sneezing, lifting. More often seen in women Incontinen Mixed: Urine loss that combines both urge and ce- stress Involuntar Chronic retention: loss of urine because bladder is y loss of not completely empty after voiding. May be an obstruction, ineffective detrusor muscle, spinal urine lesion Functional: unable to reach the toilet Neurogenic Bladder Dysfunction: Lower urinary problem caused by a central nervous system disease 16 Symptoms of Urinary Alterations (Table 44.2 pg. 1170 ) Incontinence Oliguria Urgency Nocturia Dysuria Dribbling Frequency Hematuria Hesitancy Elevated post residual urine Polyuria 17  Focus on: Nocturia Waking up one or more times to void during the night Prevalence increases with age Several health conditions, lifestyle and personal habits Prostate enlargement Heart failure Obstructive sleep apnea Hyperglycemia +Caution: Micturition syncope – sit when voiding and gradually stand up 18 Focus on Urinary Retention (Bladder is not able to empty completely) Clinical Manifestations: Pressure in lower abdomen Discomfort Tenderness over symphysis pubis, Restlessness Diaphoresis Incontinence due to overflow of small amount of urine 19  Problems with the detrusor muscle Obstruction in the urethra Post partum Urogenital surgery Certain Medication Why? Fecal impaction Anesthesia and sedating medications Enlarged prostate Pelvic organ prolapse Central nervous system – reduced sensory innervation of the bladder 20 Alterations: Urinary Diversions Urostomy, Ureterostomy, Nephrostomy Urostomy: When bladder is surgically removed, due to cancer or other disease, there is a need for urine to leave the body using an alternate route. The surgeon uses intestine to create a tube from the kidneys to the outside of the abdominal surface, forming a ‘urostomy’ The patient will wear a bag over the opening ( stoma) to collect the urine. The bag will be emptied throughout the day. 21 Common Alterations: Chronic Renal Failure Irreversible damage to kidneys Clinical Manifestations: Decreased urinary output, increased nitrogenous wastes in the blood, increasing inability of kidney to maintain fluid and electrolyte balances, nausea, vomiting, headache Influencing factors: multicomplex, high incidence of diabetes causing renal failure Outcome: may lead to peritoneal or hemodialysis, or kidney transplant More on this in second and third semester. 22  General Assessment: Assess urine and urinary elimination patterns for each patient (see next slide for prostate issues) Assess skin and mucous membranes for Assessmen fluid imbalances, dryness, skin integrity t: Clinical Assess for pain or discomfort when Manifestati voiding or pain in abdomen ons Assess vaginal area for rash, discharge, reported tenderness Assess in males : meatus ( opening at the end of the penis) for any redness, tenderness or discharge 23 The Prostate Gland Function: To produce the fluid portion of semen. Relevance to urination: Prostate enlarges as men age Causes pressure on the urethra leading to urinary retention Clinical manifestations: frequency of urination nocturia incontinence of urine dribbling of urine and weak stream 24 Circumcision YOUNGER MALE MALE UNCIRCUMCISED 25 Assessment: Fluid balance- retaining fluid or not?  Daily weight most important to know fluid status  Need to know the amount of fluid the body has taken in and the amount it has gotten rid of to consider if fluid is being retained or lost Add up the intake and output and determine fluid balance for 24hrs Report if difference varies by over 200 either positive or negative. Keep in mind approx. 500 mL /day of water is lost due to insensible water loss. An output of less than 30 mL/hour or over 2000 mL/day is of concern and needs to be reported! 26 Assessment of urine Color: pale, straw colour (normal) to amber (dehydrated) Red color: not normal, could be due to blood, medications, food, dyes from diagnostic testing Clarity: normal- transparent – may be cloudy if bacteria is present or if it sits out of body too long Odor: normal- non offensive, a change may be due to food, medications, infection, diabetic condition or lack of fluid intake Sediment: normal- none to minimal, more than that is a concern -often observed in catheter tubing 27 Assessing Urine Color 28 Assessment: Data from Diagnostics (Table 44.3 pg. 1173 & skill box 44.1 pg. 1174) Quick screening: dip and observe for any color changes on the dipped stick Urine Culture: Sterile collection ( from catheter) or clean ( midstream) sent to lab for analysis of bacteria and other findings ( RBCs) Specific gravity: Urine collected as above and is tested for the concentration of dissolved particles in the urine Other Diagnostic tests: Don’t have to learn this semester (example KUB, CT, IVP) Results: pH= 4.6-6, none or up to 8mg/100 mL, no glucose, no ketones, up to 2 red blood cells, no bacteria and no casts 29 Assessment: Influencing Factors on Urination Psychological factors: Emotional stress, Anxiety, Privacy Sociocultural factors: Gender, religious practices, social determinants of health: education, finances, literacy Fluid balance: Body adjusts- decreases or increases urine production Other substances that increase urine production? 30  Diagnostic procedures: some tests require medications that affect a person’s fluid output. Example: laxatives before a colonoscopy lead to increased output of stool thereby decreasing the amount of water released for urine production. Assessme nt: Surgical Procedures and Significant Injury/Physical Stress Influencing During and after surgery the body goes into Factors on ‘physical stress’ response and conserves Urination water, resulting in a decrease in urinary output Anesthetics and sedation, including epidurals (birth) will decrease the output of urine. Within 12 – 24 hours post op, diuresis begins 31  Assessment: Influencing Factors on Urination Disease conditions: Diseases of any of the systems involved with urination ◦Stroke: 40 – 60 % will have incontinence with 15 % remaining incontinent one year later ◦Muscular sclerosis: 30 – 50 % experience incontinence ◦Parkinson’s disease and other neuromuscular chronic illness ◦Cognitive impairments: Alzheimer’s Disease ◦Kidney disease ◦Diarrhea ◦Urinary tract infection 32  Growth and Development ◦ Aging: kidney’s function declines with age, detrusor muscle contractility Assessme diminishes, hormonal changes in women, prostate changes in men nt: Influencing ◦ Box 44-2 pg. 1170 Factors on ◦ Important to know why older persons Urination more at risk of UTI and how to help prevent, treat urinary problems. ◦ Incontinence is not normal at any age. 33 Assessment: Influencing Factors on Urination Medications: May affect the amount of urine produced and released I.e., diuretics (water pills) May change the colour of the urine 34 Common Nursing Diagnoses Urinary incontinence (overactive bladder) related to …….. Urinary retention related to ……………………. Disturbed body image related to ……………. Pain, acute related to ………….. Self-care deficit, toileting related to …………………… 35  Normal urinary elimination may not be possible, at least in the short term. Continuity of the care plan is essential! Examples of goals related to altered urinary elimination: Common Patient will urinate within 4- 6 hours Goals/Outco Patient will have a urinary output of mes greater than 300 mLs with each voiding Patient will verbalize feelings about incontinence once during shift Patient will demonstrate proper technique for self-catheterization by the end of the shift 36  Health Promotion- healthy self-care Nursing practices interventi Regular micturition, every 3-4 hours, ons to how to stimulate voiding, importance of routine, adequate fluid intake, proper help with selection and use of incontinent urinary products, hygiene, healthy intake eliminatio n 37  Health Teaching in Acute Care ◦ Orientate the patient and family to their surroundings: the bathroom, call bell in bed and in the BR, urinary products if needed. ◦ Plan more time to get to the bathroom- it is more complicated than at home ◦ Ask for help. Beds are often higher than at home, and a person may be weaker. Mobility aids are available. ◦ Tubes, IV, and monitors may need to be disconnected and reconnected. Call for assistance. ◦ Incontinence is not unusual in the hospital. Report this to a nurse asap. Keeping dry is important to prevent skin irritation and breakdown. ◦ Don’t rush getting to the toilet. Don’t rush when on the toilet. Emptying the bladder may take longer than usual. 38 Nursing interventions to help with urinary elimination Health teaching: Fluids and foods: ◦Increase fluids, especially if indwelling catheter ( unless otherwise ordered) ◦Avoid alcohol, aspartame, caffeine as they are known to irritate the bladder Lifestyle changes: ◦Reduce/quit smoking ◦Weight loss ◦Exercises to strengthen the pelvic floor 39  Nursing Interventions Maintain skin integrity: proper use of adult incontinent products and prompt and thorough skin care Urine is very irritating to skin! Promote comfort Assist with bladder control and promote continence Implement a bladder training program: habit retraining and prompted voiding/timed toileting Teach self-catheterization if ordered and patient able to perform Administer/teach about medications that may help 40  Promote complete bladder emptying, don’t rush, use bladder scanner, or in and out catheter to assess residual as needed Nursing Prevent infection; practice good Interventio hygiene ns to help Ensure privacy, maintain safety with and patient dignity urinary Prompt answering of call bells eliminatio Easy placement of urinals and prompt emptying n Administer medications as ordered for urinary conditions Catheter care 41  1. Know the reason for any indwelling catheter a. Medical reasons: Urinary retention b. Renal dysfunction that cannot be corrected surgically or medically c. Wound management or pressure ulcers after other measures have been tried and not effective in keeping the area dry Catheter d. Patient preference if other treatments Care have failed. 2. Perineal care every shift, ensuring the catheter is cleansed as well as the perineal area 3. Care of drainage bag 4. If blockage: irrigate, consider removing and re-inserting 5. Consult with physician to discontinue 42 Terminology: Catheters Indwelling catheter: A tube is inserted into the urethra and held in place by a balloon filled with sterile water. The catheter is connected to a bag (foley) to collect urine. Purpose: used when a person cannot empty their bladder, does not have sensation to urinate (post- operative or birth) or if incontinence is leading to skin impairment. Used to assess functioning of kidney and overall body response to critical illness (i.e. shock )as it provides accurate measurement of urinary output. 43 Self Condom Catheter Catheterization Urethral and Suprapubic Catheter 44  Condom Catheter: Non-invasive. A condom with an attached tube is fitted over the penis. The tube connects to a collection bag and emptied frequently. Intermittent Catheter: A tube without the balloon device is inserted to relieve the accumulation Terminolog of urine from the bladder y: Self-Catheterization: the process of inserting a catheter into your own Catheters bladder to release the urine Suprapubic catheter: A permanent insertion done by surgery of a tube (catheter) through the abdomen directly into the bladder. This system bypasses the urethra. Used when the urethra is not functioning due to blockages , disease , trauma. 45 Potenti al Sites of Infecti on Continuous Bladder Irrigation Prevents urinary tract blockage caused by clots (post-op bladder or prostate surgery) flushes irritants, helps dissolve small calculi, reduce inflammation of the bladder Can become blocked, lead to infection & discomfort Care: meticulous catheter care, ensure irrigation fluid infusing as per physician order, monitor output, manual irrigation as needed, health teaching and comfort care  Evaluate whether goals have been reached and if interventions were successful Document fluid balance, if ordered Evaluation If a patient has a catheter, you need to of Goals measure output every shift Specifically ask if the patient feels if they have better control of their bladder. Are they more satisfied with their ability to ‘pass water’? Refine the care plan in collaboration with patient and family. 48