Urinary Elimination - Nursing Lecture Slides PDF

URINARY ELIMINATION Chapter 38  WHAT ARE THE COMPONENTS OF THE URINARY SYSTEM? Kidneys and Bladder Urethra ureters  KIDNEY AND URETERS Excrete waste product (urine)...

URINARY ELIMINATION Chapter 38  WHAT ARE THE COMPONENTS OF THE URINARY SYSTEM? Kidneys and Bladder Urethra ureters  KIDNEY AND URETERS Excrete waste product (urine) The nephrons maintain Filter and excrete and regulate fluid Maintain composition blood constituents not balance through the and volume of body needed; retain those mechanisms of selective fluids reabsorption and that are needed secretion of water, electrolytes, and other substances Urine from the nephrons empties into the kidneys  BLADDER Serves as a Smooth muscle sac temporary reservoir innervated by ANS for urine Composed of three layers of muscle tissue Sphincter guards called detrusor muscle opening between The inner longitudinal urinary bladder and layer, the middle circular layer, and the urethra outer longitudinal layer Urethra conveys urine from bladder to exterior of body  URETHRA Transports urine from the bladder to the outside of the body *Nutrition: * Fluid/Electrolytes & foods and Acid-Base balance: fluids maintaining ingested homeostasis; kidneys affect urinary retain or eliminate elimination water and electrolytes (as well as (a change in bowel). electrolyte balance can influence neuromuscular *Changes in cognition transmission of increase the potential smooth muscle, thus for complications in reducing or increasing urinary eliminations *Lack of mobility intestinal peristalsis and can result in can result in inability to obtain and ineffective maintain fluid and food urinary intake. It can also lead elimination (and to inability to possible stasis recognize cues for of urine making elimination- leading to the bladder a incontinence). reservoir for bacteria).  WHAT IS MICTURITION (VOIDING)? The process of emptying the bladder T h e ur when ge to voi t d abou he bladd starts Voiding is an involuntary act that is typically t e urine 150-250 r has controlled later in life (after infancy). ml of er An g n n o l o in fun invol u h a t n ca he bra ry inc ction ntar rt t ju on y d d e led b y eo r i n r tin is ter loss Bla control diseas bladde en ce med of bl be use of nomic uri a na dder a to bec lled au ry is ca  THE ACT OF MICTURITION Detrusor muscle contracts, internal Inother words… sphincter relaxes, urine ❖ Bladder distends enters posterior urethra ❖ Voiding reflex is activated. Muscles of perineum and ❖ Person has the urge to external sphincter relax void. Muscle of abdominal wall ❖ Voiding takes place. contracts slightly ❖ Bladder fills again and the Diaphragm lowers, process is repeated. micturition occurs  VOIDING FREQUENCY Frequency of voiding depends on the amount of urine produced Those who urinate infrequently tend to be more at risk for UTIs or kidney diseases Urinary retention: urine is produced normally, but urine is not excreted completely. This can be due to certain medications, post surgery, enlarged prostate and vaginal prolapse  FACTORS AFFECTING URINATION Developmental considerations Toilet training Effects of aging Food and fluid intake Psychological variables Activity and muscle tone Pathologic conditions Medications  DEVELOPMENTAL CONSIDERATIONS Children Effects of aging Toilet training 2 to 3 Nocturia years old, enuresis Increased frequency Urine retention and stasis Voluntary control affected by physical problems Urge incontinence  FOOD AND FLUID INTAKE Kidneys aid in balance of fluid intake and output Alcohol and caffeine- acts like a diuretic Diets high in sodium decrease urine excretion  PSYCHOLOGICAL ASPECT Anxiety/ embarrassment Stress can cause smaller excretion amounts which leads to incomplete emptying Culture  ACTIVITY Regular activity promotes optimal urine production and elimination Prolonged immobilization and catheter use decreases bladder and sphincter tone and leads to poor urinary control and stasis  PATHOLOGIC CONDITIONS Infection or inflammation Calculi or tumors Hypertrophy of the prostate Cardiovascular and metabolic disorders Immobility and Impaired communication Cognitive changes  DISEASES ASSOCIATED WITH RENAL PROBLEMS Congenital urinary Polycystic Urinary Urinary tract kidney tract calculi abnormaliti disease infection es Connective Hypertensi Diabetes Gout tissue on mellitus disorders NORMAL VS DISEASED KIDNEY POLYCYSTIC KIDNEY DISEASE DIABETES & GOUT  OTHER DISEASES THAT INTERFERE WITH ELIMINATION Arthritis Parkinson’s DJD Cognitive deficits/psychiatric issues Fever Diaphoresis Heart failure  AKI, CKD, & RENAL FAILURE AKI (acute kidney injury) is sudden kidney dysfunction within hours or days but is reversible if caught early. CKD (chronic kidney disease) is steady loss of kidney function that occurs over several months and/or years Renal failure occurs when the kidneys fail to filter metabolic end products from the blood and fail to regulate fluid, electrolyte and pH balance. POP QUIZ: WHAT’S ANOTHER NAME FOR THE FINAL STAGE KIDNEY/RENAL FAILURE? ESRD: End Stage Renal Disease  MEDICATIONS Drugs that are known for causing kidney damage are considered nephrotoxic drugs. Diuretics Antibiotics Analgesics (ASA, ibuprofen)  MEDICATIONS Cholinergics – stimulate contraction of detrusor muscle, producing urination Anticholinergics – used to treat incontinence by way of decreasing urgency and decreasing the production of urine (causes urinary retention) Diuretics -- commonly used in the treatment of hypertension & other disorders, prevent fluid reabsorption of water certain electrolytes in the tubules. Depending on the dose of the drug, diuretics cause moderate to severe increases in production and excretion of dilute urine Antimuscarinic agents – reduces involuntary detrusor contractions and increase bladder capacity (may be useful for urgency urinary incontinence)  MEDICATIONS Alpha Blockers – prevents, treats or improves symptoms of an enlarged prostate (benign prostatic hyperplasia) by relaxing the muscle of the prostate and bladder neck, which allows urine to flow more easily 5-alpha reductase inhibitors – By inhibiting the production of dihydrotestosterone (DHT) locally within the prostate gland, 5alpha- reductase inhibitors have the effect of reducing prostate volume, improving lower urinary tract symptoms, increasing peak urinary flow, and decreasing the risk of acute urinary retention and need for surgical intervention Estrogen – Topical estrogen may be used in postmenopausal women to relieve atrophy of involved muscles; treats urinary incontinence Antidepressants– makes the bladder muscle relax, while causing the smooth muscles at the bladder neck to contract; used to treat mixed incontinence  MEDICATIONS ANTICOAGULANTS: RED DIURETICS: PALE YELLOW PYRIDIUM: ORANGE TO THE ANTIDEPRESSANT LEVODOPA: BROWN OR URINE URINE ORANGE-RED URINE AMITRIPTYLINE OR B- BLACK URINE COMPLEX VITAMINS: GREEN OR BLUE-GREEN URINE  NURSING PROCESS FOR URINARY ELIMINATION Assessment Diagnosis Planning Implementation Evaluation  ASSESSMENT History: what brought the client in today? Guide 38-1 Duration, severity, and possible factors Physical assessment: use assessment skills Findings: correlating the history and assessment together to make a formal diagnosis  ASSESSMENT: PHYSICAL Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner ASSESSMENT 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 (table 38-1) * Always check your orders before bladder scannin g!  ADDITIONAL ASSESSMENT TECHNIQUES Measuring urinary output Routine urinalysis Continent patients (figure 38- Clean-catch or midstream 5, box 38-2) specimen Incontinent patients Sterile specimen Indwelling catheter Urinary diversion specimen 24-hour specimens  ADDITIONAL ASSESSMENT TECHNIQUES: MEASURING URINARY OUTPUT Ask the patient to Put on gloves. Pour Place the calibrated void into a bedpan, urine into the container on a flat urinal, or specimen appropriate surface and read at container in bed or measuring device eye level bathroom Discard urine in the toilet unless Note amount of specimen is needed. urine voided and If a specimen is record on the required, pour the appropriate form urine into an appropriate specimen container  COLLECTING URINE SPECIMEN Fresh void- patient voids right then and there Clean catch- patient cleans genitalia, starts voiding, stops midstream and catches the remaining urine Sterile urine- obtained from catheter (in and out or indwelling) 24-hour urine collection-discards the first urine and begins collection of urine in a large container that is kept on ice for 24 hours STERILE SPECIMEN COLLECTION  SPECIMEN FROM A URINARY DIVERSION DEVICE For patients with a urostomy, sterile specimen can be collected in one of three ways: Sterile catheterization of the stoma site Clean-catch drip New studies show that a clean urostomy pouch can be used to sterile specimen as well  URINALYSIS/CULTURE & SENSITIVITY This has many components and studies the urine more closely. Usually done in the lab. ➔ Color ➔ Odor ➔ Turbidity/Clarity ➔ pH ➔ Specific Gravity ➔ Constituents  IMPORTANT LABS TO CONSIDER BUN : 8-20 mg/dL Creatinine : 0.6-1.2 mg/dL (men), 0.4-1 mg/dL (women) Specific Gravity : 1.015- 1.025  DIAGNOSIS After assessment of the patient’s urinary system and elimination patterns, the nurse collaborates with other nursing and healthcare professionals to discuss findings and adds this in the patient’s health record.  POTENTIAL PROBLEMS: URINARY ELIMINATION Urinary retention Stress incontinence – “Sometimes when I laugh, cough, sneeze, or move to quick, I feel like I’m leaking.” Urge Incontinence- sudden urge to void resulting in accidental leaks (UTIs)  CYSTOSCOPY This procedure is the direct visualization of the urethra, bladder, and ureteral orifices by using a scope. Examples include bladder infections, bladder cancer and urinary tract stones  PYELOGRAM IVP- uses IV contrast to evaluate renal function by analyzing the flow of contrast over time Retrograde pyelogram- uses contrast directly through catheter to visualize the renal collecting system POP QUIZ: What should the nurse take into consideration with both tests? Shellfish allergy  RENAL ULTRASOUND Used to visualize renal parenchyma (functional tissue) and renal blood vessels. Can help characterize renal masses and infections, visualize large calculi, detect malformed kidneys, provide guidance for procedures like biopsies, and monitor status of renal transplants and kidney development in kids with congenital diseases.  COMPUTED TOMOGRAPHY More detailed scan than an x-ray  PLANNING Planning and expected outcomes come next. Examples: “the patient will empty the bladder completely at regular intervals” or “the patient will report ease of voiding”  IMPLEMENTATION Interventions include maintaining and promoting normal urinary patterns, improving or controlling urinary incontinence, preventing problems associated with bladder catheterization and helping with care of urinary diversions.  PROMOTING URINARY ELIMINATION Produce urine output about equal to fluid Produce intake Maintain Maintain fluid and electrolyte balance Empty bladder completely at regular Empty intervals Report Report ease of voiding Maintain Maintain skin integrity Demonstrate appropriate self-care Demonstrate behaviors  CARING FOR PATIENTS: UTI Most common cause of systemic infections in the older population Which gender is the most vulnerable to UTIs? Why? Diagnosis: Nursing history + physical exam + labs E. Coli is a common uti UA & culture and sensitive bacteria Treatment/Education: Abx Drink water daily Urinate when urged to Females: wipe front to back Void before and after intercourse Repeated UTIs may be a result of contraceptive use Cotton underwear and loose-fitting clothing  CARING FOR PATIENTS: INCONTINENCE Transient: suddenly appears and is usually accompanied by a treatable illness or temporary issue. Stress incontinence Urge incontinence Mixed: stress + urgency incontinence Overflow: chronic retention of urine resulting in involuntary loss of urine due to overflow/overdistention Functional: urine loss due to inability to reach the toilet Reflex: emptying of the bladder without voiding sensation from nerves that have signals sent from the brain Total: urination can’t be controlled  CARING FOR PATIENTS: INCONTINENCE Assessment Assess environmental factors for potential barriers Would the patient benefit from toileting equipment or equipment needed to make it to the toilet safely (cane, walker, etc)? Dietary habits Voiding patterns (void diary) Postvoid residual- bladder ultrasound Treatment See box 38-5  CARING FOR PATIENTS: INCONTINENCE Incontinence-associated dermatitis Skin care is important- How can we prevent IAD? Regular skin assessments, skin cleansing, moisturizers or emollients to restore skin and barrier protectants  EXTERNAL COLLECTION DEVICES Urinary sheath or condom catheter Purewick for men and women NURSING INTERVENTIONS Urethral catheter insertion and care for patients with an indwelling catheter Caring for a patient with a urologic stent Caring for a patient with a urinary diversion Caring for a patient receiving dialysis  REASONS FOR CATHETERIZATION Relieving urinary retention Obtaining a sterile urine specimen when client is unable to void voluntarily Accurate measurement of urinary output in critically ill clients Assisting in healing open sacral or perineal wounds in incontinent clients Emptying the bladder before, during, or after select surgical procedures and before certain diagnostic examinations. Providing improved comfort for end-of-life care Prolonged client immobilization (potentially unstable thoracic or lumbar spine, multiple traumatic injuries)  TYPES OF CATHETERS Intermittent Indwelling Suprapubic urethral urethral catheter catheters catheter  INTERMITTENT CATHETER Obtaining a sterile Accurate Assisting in healing urine specimen Relieving acute measurement of open sacral or when patient is urinary retention urinary output in perineal wounds in unable to void critically ill patients incontinent patients voluntarily Emptying the bladder before, during, or after Providing improved select surgical Prolonged patient comfort for end-of- procedures and immobilization life care before certain diagnostic examinations  TYPE OF CATHETERS ❖ Straight - this is a one time use catheter. ❖ Indwelling- stays for a while depending on client condition; continuous drainage ❖ Suprapubic- surgical incision where catheter is placed for continuous drainage  CATHETER INSERTION: INDWELLING INSERTION OF URINARY CATHETER:​ 1. Prepare catheter tray observing sterile technique 2. Cleanse the female or male meatus appropriately. Using sterile technique​ ​ 3. With the sterile gloved hand grasp the catheter firmly 2-3 inches from the tip, insert the catheter without contacting any skin other than the meatus. ​ For a female client Advance the catheter 1-2 inches further after urine is visualized in the catheter tubing.​For a male client insert the catheter to the bifurcation. ​Male and Female While holding the catheter in place, inflate the balloon with designated amount of solution. Pull gently on the catheter until resistance is felt, to ensure that the balloon has inflated and to place it in the trigone of the bladder.​​ 4. Secure catheter tubing appropriately.​ ​ 5. Secure bag appropriately below level of bladder.​ ​ Indwelling foley 6. Maintained sterility throughout the procedure.​ https://youtu.be/2p9zlA0pB wU  CATHETER INSERTION: https://www.youtube.com/watch?v=UQEaCzV3 Tog INTERMITTENT 1. Bladder scan bladder. For purposes of class, if bladder is >200mL, protocol is to in and out (intermittent) 2. Prepare catheter tray observing sterile technique 2. Cleanse the female or male meatus appropriately. Using sterile technique​ ​ 3. With the sterile gloved hand grasp the catheter firmly 2-3 inches from the tip, insert the catheter without contacting any skin other than the meatus. ​For a female client Advance the catheter 1-2 inches further after urine is visualized in the catheter tubing.​For a male client insert the catheter to the bifurcation. ​ 4. Drain the appropriate amount of urine into intermittent bag 5. After enough urine drainage, let the patient know that you will be pulling the catheter out. Carefully begin pulling catheter from urinary meatus. Be careful not to let catheter tip swing everywhere. 6. Bladder scan for post void residual THREE-WAY CATHETER: IRRIGATION  CARING FOR PATIENTS: UROLOGIC STENT Used to allows for urine passing in When the nurse notices bright the event of a blockage (such as red urine, severe pain in the renal calculi) and prevent swelling of patient, urine pattern changes, the ureter or signs of infection, what should the nurse do? Temporary (ureters) & permanent *Let the doctor know ASAP (urethra) Placed during surgery or cystoscopy Nursing responsibilities: monitoring urine output (color, consistency, odor), signs of infection or bleeding, decreased output  CARE OF PATIENTS: UROSTOMY -A stoma (ileal conduit) is formed with a piece of the ileum and creates a pouch that drains the urine. (figure 38-15)  CARE OF PATIENTS: CUTANEOUS UTEREROSTOMY & CONTINENT URINARY DIVERSION  CARING FOR PATIENTS: DIALYSIS Used for severely decreased or total kidney function loss Filters waste and extra electrolytes mechanically Hemodialysis vs peritoneal dialysis (PD)  EVALUATION Continuous nursing process Questions the nurses should reflect on: Has the patient showed a positive or negative outcome during the care? Were individualized goals met for the patient? Are there any adjustments needing to be made?  MATCH THE TERMS a. Nocturia 3 1. Pus in urine b. Nocturnal enuresis 6 2. Urine output less than 400ml in 24 hours c. Oliguria 2 3. Frequent urination after going to bed d. Polyuria 5 4. Strong desire to void e. Pyuria 1 5. Excessive urination f. Urgency 4 6. Involuntary loss of urine while sleep  MATCH THE TERMS a. Anuria 2 1) 1. To urinate b. Dysuria5 2) 2. Absence of urine; urine output less c. Enuresis 7 than 50ml in 24 hours d. Frequency 6 3) 3. Blood in the urine e. Hematuria 3 4) 4. A substance that damages kidney f. Micturition1 tissue g. Nephrotoxic 4 5) 5. Painful or difficult urination 6) 6. Increased incidence of voiding 7) 7. Involuntary loss of urine ANY QUESTIONS?