Urinary Elimination PDF

Chapter 46 Urinary Elimination NURS 300  Objectives 1. Explain the function and role of urinary system in urine formation and elimination 2. Identify factors that commonly impact urinary elimination 3. Compare common alterations associated with...

Chapter 46 Urinary Elimination NURS 300  Objectives 1. Explain the function and role of urinary system in urine formation and elimination 2. Identify factors that commonly impact urinary elimination 3. Compare common alterations associated with urinary elimination 4. Compile a nursing history from a patient with an alternation in urinary elimination. 5. Demonstrate a physical assessment focused on urinary elimination. 6. Interpret features of normal and abnormal urine. 7. Appraise nursing implications of common diagnostic tests of the urinary system. 6. Select nursing diagnoses associated with alterations in urinary elimination 7. Discuss nursing interventions to promote normal urinary elimination. 8. Discuss nursing interventions to reduce the risk of urinary track infections ( UTI’s) 9. Summarize nursing interventions that prevent catheter-associated urinary track infections (CAUTI’s). 10. Describe nursing interventions for patients with urinary incontinence (UI). 11. Demonstrate safety skills using clinical judgement associated with assessment and promotion of urinary elimination.  Organs of Urinary Elimination Kidneys Ureters Remove waste from blood to Transport urine from kidneys to form urine bladder Bladder Urethra Urine travels from the bladder Reservoir for urine until the urge and exits through the urethral to urinate develops meatus.  Urinary System Kidneys filter waste products of metabolism that collect in the blood. Nephron - functional unit of kidney, urine is formed Ureters - tubular structures, enter urinary bladder. Urinary bladder -hollow, distensible, muscular organ (detrusor muscle) stores & excretes urine Urine exits bladder through urethra & passes out of body through urethral meatus women - urethra is 3 to 4 cm long Short length predisposes women & girls to infection. men - urethra is about 18- 20 cm long  Act of Urination Brain structures influence bladder function. Voiding: Bladder contraction + Urethral sphincter and pelvic floor muscle relaxation 1. Stretching of bladder wall signals micturition center in sacral spinal cord. 2. Impulses from micturition center in brain respond to or ignore urge, making urination under voluntary control 3. When ready to void (bladder fills to approx. 400-600 mL), external sphincter relaxes, micturition reflex stimulates detrusor muscle to contract, & bladder empties. Bladder capacity ranges from 600 to 1000 mL of urine; an adult normally voids every 2 to 4 hours.  Factors Influencing Urination Disease conditions Medications and medical procedures Socioeconomic factors (need for privacy) Psychological factors (anxiety, stress, privacy) Fluid balance Disease Conditions Affecting Urination Prerenal, renal, postrenal classification Conditions of the lower urinary tract Diabetes mellitus & neuromuscular diseases such as MS Benign prostatic hyperplasia Cognitive impairments (e.g., It Alzheimer’s) Diseases that slow or hinder physical activity Conditions that make it difficult to reach toilet facilities End-stage renal disease, uremic syndrome  Nursing Knowledge Base Infection control and hygiene - The urinary tract is sterile. Use of infection control principles help prevent UTIs. Increased fluid intake results in increased diluted urine formation, & reduces risk of UTI Growth and development - Infants, children, & elderly experience problems with urination. Young need to learn to recognize need to urinate. Elderly have decreased functioning that accompanies aging. Muscle tone - Weak abdominal & pelvic floor muscles impair ability of urinary sphincter to maintain tone. Immobility, muscle damage during vaginal delivery, & E muscle atrophy or trauma contribute to problems with urination Psychosocial considerations - body image, self-esteem, roles, & identity may influence urination Cultural considerations - Urinary problems may not be treated in the western tradition. Culture may dictate how and when a patient urinates. In some cultures, patients urinate in a squatting position.  Assessment Nursing history Patterns of urination Symptoms of urinary alterations Factors affecting urination Physical assessment Body systems affected by urinary change (skin and mucous membranes, kidneys, bladder, urethral meatus) Characteristics of urine (color, clarity, odor) Intake and output Relevant lab and diagnostic test data Perception of urinary problems (self-concept, sexuality)  Common Symptoms of Urinary Alteration An immediate and strong desire to void that is not easily deferred Causes: Full bladder, UTI, Inflammation of bladder, overactive bladder Urgency catheter pimpoperylacing Pain or discomfort associated with voiding Causes: UTI, Inflammation of prostate, Trauma to urinary tract, tumors Dysuria Voiding more than 8 times during waking hours and/or ad decreased intervals, such as less than every 2 hours Frequency Causes: High volumes of fluid intake, bladder irritants (Caffeine), UTI, Increased pressure (pregnancy) Delay in start of urinary stream when voiding Causes: Anxiety (voiding in public), Bladder outlet obstruction (prostate enlargement, urethral stricture) Hesitancy Diminished urinary output in relation to fluid intake Causes: Dehydration, kidney dysfunction or failure, increased secretion of ADH, urinary tract Oliguria obstruction  Common Symptoms of Urinary Alteration Awakened from sleep because of the urge to void Causes: Excess intake of fluid (especially coffee or alcohol before bedtime), bladder outlet obstruction (prostate), overactive bladder, medications (diuretics taken in the evening), UTI Nocturia Leakage of small amounts of urine despite voluntary control of matriculation Causes: Bladder outlet obstruction (prostatic enlargement), incomplete bladder emptying, stress incontinence Dribbling Presence of Blood in urine. Gross Hematuria is blood easily seen in urine. Microscopic hematuria is blood not visualized but measured on urinalysis Causes: Tumors (kidney, bladder), infection, Urinary tract calculi, trauma Hematuria Acute Retention: Suddenly unable to void when bladder is adequately full or overfull Chronic retention: Bladder does not empty completely during voiding, and urine is retained in the bladder. Causes: Bladder outlet obstruction (prostatic enlargement, urethral obstruction), Absent or weak Retention bladder contractility, Side effects of medications  Common Urinary Elimination Problems Urinary tract Urinary Urinary Urinary infection retention incontinence diversion (UTI) Can result from catheterization or procedure – Most common HAI. E. coli is most common Involuntary leakage pathogen of urine Accumulation of urine d/t inability of bladder Diversion of urine to to empty. Bladder 4th most common type external source - ileal distention is apparent. of health loop or conduit, Pt may void small care-associated continent pouch, and amounts of urine 2 to infection nephrostomy 3 times/hour, no real relief very prevalent in Classified by location elderly – But not a upper urinary tract normal sign of aging (kidney), lower urinary tract (bladder, urethral)  Case Study- Retention Mrs. JA is a 65-year-old woman who has been in the hospital for 4 days with problems related to heart failure, fluid retention, and diabetes. She has a history of urinary retention secondary to neuropathy caused by her diabetes. Mrs. JA’s indwelling urinary catheter was removed 2 days ago and subsequently was replaced yesterday at 6 a.m. because of her inability to urinate more than 100 mL at a time, being incontinent of small amounts of urine, complaints of urinary urgency, and lower abdominal pain. Sandy, the nursing student, learns about Mrs. JA at the 3 p.m. shift report. What questions would you have if you were Sandy?  w a des then ok 11 a a ays I's O's Case Study- Retention Sandy notes that the urinary catheter was removed at 7 a.m. this morning, and the patient has no recorded urine output for the day. JA verifies that she has only “dribbled” urine. While making rounds, Sandy talks with JA, who says she is worried because “I thought this was all under control.” The health care provider is notified, and an order is obtained for an intermittent catheterization. The registered nurse on the day shift catheterizes Mrs. JA at 3 p.m. with a return of 600 mL of pale, clear yellow urine. What do you think is happening with JA? she is urine Case Study- Retention Assessment Findings: Bladder is able to palpated, indicating bladder distention. During palpation, patient states she has the sensation of bladder fullness. Patient complains of dribbling frequently and being unable to urinate. What are some specific interventions to help improve JA’s urinary retention? Assist with toileting every 2 to 3 hours while awake. Instruct the patient/family to record urinary output as appropriate. Have JA take a warm bath if unable to urinate. Use Credé’s method with each attempted void (requires provider order)- manual compression of bladder to assist in emptying  UTI Pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, & malaise as infection worsens Irritated bladder (cystitis) causes frequent & urgent sensation of need to void. Irritation to bladder & urethral mucosa results in blood-tinged urine (hematuria). Urine appears concentrated & cloudy because of presence WBCs or bacteria. If infection spreads to the upper urinary tract gicchangesIderadult_scanidenhfy (kidneys—pyelonephritis), flank pain, tenderness, fever, & chills  Incontinence Transient – Incontinence caused by medical conditions that in many cases are treatable and reversible Functional – Loss of continence because of causes outside the urinary tract Often related to functional deficits such as altered mobility and manual dexterity, cognitive dexterity, cognitive impairment, or poor motivation Direct result of caregivers not responding in a timely manner to requests Overflow – Urinary incontinence associated with chronic retention Loss of urine caused by an overdistended bladder often related to bladder outlet obstruction or poor bladder emptying because of weak or absent bladder contractions Stress – Involuntary leakage of small volumes of urine associated with increased intra-abdominal pressure Weakness or injury to urinary sphincter or pelvic floor muscles Underlying result: urethra cannot stay closed as pressure increases in the bladder as a result of increased abdominal pressure (i.e. sneeze or a cough) Urge or urgency – Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction Caused by involuntary contractions of the bladder associated with an urge to void that causes leakage or urine Reflex – Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord 17 damage, patient has diminished or absent awareness of urge to void  Urinary Diversions Urinary diversion - Pts who have had the bladder removed (cystectomy) d/t cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI, require surgical procedures- divert urine to outside of body through opening in abdominal wall called a stoma  Nephrostomy Tubes Nephrostomy tubes Tubes tunneled through skin into Placed to drain renal pelvis Patients can go home with these tubes & need careful teaching In renal pelvis I when ureter is obstructed about site care and S&S of infection  Older Adults Provide frequent opportunities to void. Older adults have smaller bladder capacity than younger adults. Encourage older adults to empty bladder completely before & after meals, & at bedtime. Encourage pts to increase fluid intake to at least six to eight glasses a day unless medically contraindicated Incontinence is not a normal part of aging, and make efforts to assess incontinence and provide interventions to promote return to continence.  Catheterization Catheterization - Latex or plastic tube through urethra into bladder Catheter provides continuous flow of urine in patients unable to control micturition, and in those with Ferwitate obstructions Intermittent straight catheterization Indwelling continuous catheterization big tube andbag Higher risk for infection  Catheterization Indwelling catheter- attached to urinary drainage bag to collect flow of urine Drainage system should not be separated unless absolutely necessary, to avoid introducing pathogens Specimens collected without opening drainage system using a port in the tubing Hang bag below level of bladder on bed frame or chair so urine will drain down – Biggest risk for CAUTI Routine catheter care Regular perineal hygiene, especially after bowel movement, to reduce the risk for CAUTI. Empty drainage bags when half full Overfull drainage bag can create tension, pull on catheter resulting in trauma to urethra, increasing risk for CAUTI. IF no urine drainage, 1st check to make sure there are no kinks or occlusion of drainage tubing or catheter. Milk and readjust the tubing to help remove any mucus or sediment that has clogged up the tubing  Catheterization Preventing CAUTI catheter associated UTI key interventions to prevent infection: Maintaining a closed system. Prevention of urine back flow Assess for need of indwelling catheter Catheter irrigations and instillations To maintain patency, it is sometimes necessary to irrigate/flush with sterile solution. Potential sites for introduction of infectious k Continuous bladder irrigation (CBI) example of continuous infusion of a sterile solution organisms into a urinary drainage system.] into the bladder,ÉÉ usually using a three-way irrigation closed system with triple-lumen catheter. CBI frequently used following genitourinary surgery  Indications for Indwelling Catheter Use Appropriate Use Inappropriate Use Acute urinary retention Convenience (i.e. Bladder outlet obstruction incontinence, confusion, Accurate urine output reduced mobility, I&O) measurement in critically Obtaining urine for ill patients diagnostic tests when the Postoperative use for certain surgical patient can voluntarily void procedures Postoperative use without Incontinent patients with appropriate indications open sacral or perineal wounds Consider Alternatives To improve comfort for end of life care if needed External catheters pyuriclecondom catheter Intermittent catheterization obtaining urine Toileting schedules try to get patients up more often  Chapter 47 Bowel Elimination  Objectives 1. Discuss the role of gastrointestinal organs in digestion and elimination. 2. Discuss psychological and physiological factors that influence the elimination process. 3. Recognize cues that help you to assess a patient's elimination pattern. 4. Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. 5. Select individualized nursing interventions using your clinical judgement that promote normal elimination. 6. Prioritize nursing interventions for patients with intestinal diversions. 7. Describe nursing procedures related to bowel elimination. 8. Use critical thinking and clinical decision making when providing care to patients with alterations in bowel elimination.  Organs of the Gastrointestinal (GI) Tract Hollow mucous membrane–lined muscular organs including F Mouth, esophagus, stomach, intestines. Accessory organs are Teeth, lounge, salivary glands, liver, pancreas and gallbladder Absorbs fluid & nutrients, prepare food for absorption & store feces Absorbs high volumes of fluids, making fluid & electrolyte balance a key function of GI system Receives secretions from gallbladder & pancreas  Segmented and Peristaltic Waves Segmentation & peristaltic movement in small intestine facilitate both digestion & absorption Small intestine has three sections: the duodenum, the jejunum, & ileum Duodenum -Processes chyme from stomach, & absorbs nutrients Jejunum - absorbs carbohydrates & proteins. Ileum - absorbs water, fats, certain vitamins, iron, & bile salts Duodenum & jejunum absorb most of nutrients & electrolytes If the digestive process of small intestines is impaired by inflammation, infection, surgical resection or obstruction this can result in great electrolyte and nutrient deficiencies Segmented and Peristaltic Waves  Divisions of the Large Intestine Colon – cecum, ascending, transverse, descending, & sigmoid colons, rectum. Three functions: absorption, secretion, & elimination. Large intestine absorbs water (up to 1.5L a day), sodium, & chloride Fast peristalsis = less time for water to be absorbed, & the stool is watery Slow Peristalsis = water continues to be absorbed, resulting in constipation. Secretory function aids in electrolyte balance. Colon excretes about 4 - 9meq of potassium daily. Alterations in colon function cause severe electrolyte disturbances. Rectum contains vertical & transverse folds of tissue that help to temporarily hold fecal contents during defecation. Each fold contains artery & vein that can become distended from pressure during straining resulting in a hemorrhoid Body expels feces & flatus through anal canal & anus Divisions of the Large Intestine connects to small intestines  Digestive Track Mouth Esophagus Digestion begins with Peristalsis moves food into the mastication. stomach. Stomach Stores food; mixes food, liquid, Small intestine and digestive juices; moves food Duodenum, jejunum, and ileum into small intestines Large intestine Anus The primary organ of bowel Expels feces and flatus from the elimination rectum  Factors Affecting Bowel Elimination Age - Infants small stomach capacity Diet - Food high in fiber content & & rapid peristalsis. Older adults increased fluid intake keep feces decrease in peristalsis & absorption soft Physical activity - promotes Fluid intake – liquefy GI contents peristalsis Personal habits – disrupting regular Psychological factors – Stress increases habits and causing possible peristalsis, & Depression decreases it alterations such as constipation Position during defecation - Supine Pain - Pt to suppresses urge to position, impossible to contract defecate to avoid pain… muscles used during defecation development of constipation Pregnancy - Size of the fetus puts Surgery and anesthesia - paralytic pressure on rectum, can cause ileus, lasts 24 to 48 hours obstruction Diagnostic tests – Cause change in Medications, laxatives, and cathartics eating pattern  Common Bowel Elimination Problems Constipation Impaction A symptom, not a disease; infrequent Results from unrelieved constipation; stool and/or hard, dry, small stools that collection of hardened feces wedged are difficult to eliminate in rectum that person cannot expel Enema or visually disimpact them Diarrhea Incontinence Increase in number of stools and Inability to control passage of feces passage of liquid, unformed feces and gas to anus Flatulence Hemorrhoids Accumulation of gas in intestines Dilated, engorged veins in lining of causing walls to stretch rectum  Bowel Diversion Certain diseases cause conditions that prevent normal passage of feces through rectum. Treatment for these disorders results in need for temporary or permanent artificial opening (stoma) in abdominal wall. Surgical openings are created in ileum (ileostomy) or colon (colostomy), with ends of intestine brought through abdominal wall to create stoma Surgical opening in ileum or colon Ileostomy or colostomy Location of colostomy determines quality and consistency of output  Descendind sigmoid copensstomed cessedmed stool stool transverse formed ascending collness stool copygoes  Tidy smash stool  Normal-Appearing Stoma Normal – bright red, moist, round, some mucous Goals: keep the patient as free of odors as possible Inspect stoma regularly Note size of the stoma Keep skin around stoma clean and dry Measure I & O Explain care Encourage patient to be involved and to look at ostomy  Assessment Normal & abnormal patterns and habits Elimination factors Elimination Esto Stool appearance Surgery or l stool form scale pattern illness Stool Medications characteristics Routines Emotional state Bowel Exercise diversions Appetite Pain or changes discomfort Diet history Social history Daily fluid Mobility and intake dexterity  Promotion of Normal Defecation Establish and maintain a routine Diet and exercise Privacy and Positioning (toilet, commode, bedpan) Hygiene and skin integrity Medications Cathartics and laxatives- Accelerate and ease defecation Anti-diarrheal agents Enemas and digital removal of stool Clear bowels, relieve impactions Require a provider order Goal: Regular pain-free defecation of soft formed stools  Decompression Decompression of the GI tract due to surgery or obstruction Large-bore nasogastric (NG) tube to gravity or hooked to suction to remove gastric contents Uncomfortable for patient Prevent migration of tube Maintain patency Assess and Measure output Constipation: Major Issue with IDD Who is at risk? Early Signs of Constipation Previous bowel Behavioral changes obstruction, abdominal surgery or abdominal Decrease in level of alertness injury Vomiting Multiple medications, especially ones that slow Increased seizure activity GI motility and have anti-cholinergic effects Fever Immobility Complications Pneumonia People who ingest non-food items (PICA) like Medication intoxication cloth, paper, plastic, or metal Bowel obstruction