NRSG 110 Urinary Elimination - PowerPoint Presentation PDF

Psychiatric Nursing Program NRSG 110 Learning Outcome 4: Urinary Elimination Chapter 44 Faculty: Susan Howell Urinary Elimination Faculty: S.Howell 1 Readings Potter & Perry, Ch. 44 Urinary Elimination Faculty: S.Howell 2 Ur...

Psychiatric Nursing Program NRSG 110 Learning Outcome 4: Urinary Elimination Chapter 44 Faculty: Susan Howell Urinary Elimination Faculty: S.Howell 1 Readings Potter & Perry, Ch. 44 Urinary Elimination Faculty: S.Howell 2 Urinary Elimination Micturition – the voiding of urine (URINATION) Urinary Elimination depends on function of: Kidneys Ureters Bladder Urethra Urinary Elimination Faculty: S.Howell 3 Scientific Knowledge Base: Organs of Urinary Elimination Kidneys Ureters Remove waste from the Transport urine from the blood to form urine kidneys to the bladder Bladder Urethra Reservoir for urine until Urine travels from the the urge to urinate bladder and exits through develops the urethral meatus 4 Urinary Elimination Faculty: S.Howell 5 Urinary Elimination Faculty: S.Howell 6 Urinary Elimination Faculty: S.Howell 7 Urinary Elimination Faculty: S.Howell 8 Physiology of the Kidneys Kidneys Filter waste products  Nephron-functional unit (waste products are removed and urine is formed)  Glomerulus-initial filtration of the blood begins urine formation (glomerulus is a capillary network of blood vessels) Other Functions:  Fluid and electrolyte balance  Hormone production Urinary Elimination Faculty: S.Howell 9 Urinary Elimination Faculty: S.Howell 10 Organs of Urination (review) Kidneys Remove waste from the blood to form urine Ureters Transport urine from the kidneys to the bladder Bladder Reservoir for urine until the urge to urinate develops Urethra Urine travels from the bladder and exits through theUrinary urethral Elimination meatus Faculty: S.Howell 11 Quick Quiz! 1. A patient with longstanding history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. What is the nurse’s response? A. Glomerulus B. Bowman’s capsule C. Nephron D. Ureter Urinary Elimination Faculty: S.Howell 12 Kidneys Produce erythropoietin which functions within the bone marrow to stimulate RBC production and maturation Produce renin which converts the hormones needed to stimulate the adrenal glands to produce aldosterone which increases water retention therefore increasing blood volume, plays a role in BP control. Renin is another hormone produced by the kidneys. Its major role is the regulation of blood flow in times of renal ischemia decreased blood flow Urinary Elimination Faculty: S.Howell 13 Urinary Elimination Introduction Basic human function Private process Nurses must be alert to cues Nurses should be prepared to discuss assessment and treatment options for concerns related to urinary elimination Nurses provide counseling and support Urinary Elimination Faculty: S.Howell 14 Urination Relies on coordinated effort of bladder & urethral closure mechanism Bladder normally holds a max of 600 mL Desire to urinate can be sensed when 250- 300 mL present in bladder…. Strong urge at 500mls Damage to spinal cord above sacral region causes loss of voluntary control of urination Urinary Elimination Faculty: S.Howell 15 Normal Adult Urine Output Depends on intake 1500-1600 mL /day …. Liters 1-2 Less than 30 mL /hr in adults indicates renal problems Newborn (age 0-30 days) and infant (up to 1 year) 1-2 ml/kg/hr Urinary Elimination Faculty: S.Howell 16 Urinary Elimination Adult Voids approximately 300-500 mL q4h Frequency common in pregnancy which can increase the incidence of UTI Prostate- frequency & retention Urinary Elimination Faculty: S.Howell 17 Urinary Elimination Older adult ↓ filtration Nocturia Bladder loses muscle tone ↓ capacity Frequency Residual urine Increased UTI Always investigate incontinence in the older adult Urinary Elimination Faculty: S.Howell 18 Factors Influencing Urination Disease conditions Fluid balance Meds Pelvic floor muscle tone Diagnostic examination Surgical procedures Psychological factors Diseases affecting renal function Urinary Elimination Faculty: S.Howell 19  Factors Influencing Urinary Function Disease Conditions that affect Renal Function (urine volume and quality)  Pre-Renal Alterations  Decreased circulating blood flow to kidneys, therefore ↓ blood flow to renal tissues  Alterations occur before the urinary system  leads to oliguria or less commonly anuria  Oliguria also occurs from fluid loss such as in dehydration, hemorrhage, CHF, nausea and vomiting  Renal Alterations  Injury directly to the glomeruli or renal tubules of the kidneys – chronic nephritis, diabetes, glomeruli transfusion reaction. Urinary Elimination Faculty: S.Howell 20 Disease Conditions (cont)  Post Renal  Obstruction to the urine flow in the urinary collecting system anywhere between the renal pelvis and the urinary meatus. Urine is formed but cannot be eliminated.  Calculi (stones), blood clots, tumors  Enlarged prostate  Damage to the nerves enervating the urinary system  End-Stage Renal Disease  Caused by irreversible damage to the kidneys  Dialysis; - peritoneal, and hemodialysis  Organ transplant  Uremic syndrome… increase in nitrogenous wastes in the blood Urinary Elimination Faculty: S.Howell 21 Hemodialysis Urinary Elimination Faculty: S.Howell 22 Peritoneal Dialysis Urinary Elimination Faculty: S.Howell 23 Alterations in Urinary Elimination Result from: Infection Impaired bladder function Obstruction to urine outflow Inability to voluntarily control micturition Interruption(s) in normal pathway of excretion Urinary Elimination Faculty: S.Howell 24 Factors Influencing Urination Fluid balance Polyuria- Diabetes mellitus Diuresis Nocturia Medications Diuretics  Anesthesia may cause urinary retention Urinary Elimination Faculty: S.Howell 25 Factors Influencing Urination Pelvic Floor Muscle (PFM) tone -voluntary and involuntary weak PFM contributes to stress incontinence Diagnostic Examinations-cystoscopy Surgical procedures – spinal or epidural anesthetics Psychological -anxiety Urinary Elimination Faculty: S.Howell 26 Quick Quiz! A 3-year-old is having problems urinating postoperatively. The nurse needs to be aware that children may have trouble voiding in which situation? A. In a urinal or bedpan while in hospital B. While lying in bed; they prefer to sit or stand C. In bathrooms other than their own D. In the presence of a person other than their parents Assessment of Urinary Status Health history Physical Assessment Pattern of urination Review lab & diagnostic tests Synthesize & Analyze Urinary Elimination Faculty: S.Howell 28 Assessment Pattern of urination Symptoms of alterations Factors affecting urination Hx Diseases Bowel elimination Meds Physical mobility Physical Examination Assessment of Urine Urinary Elimination Faculty: S.Howell 29 Health History Health history  Patterns of urination  Provides baseline data  Useful diagnostic tool for incontinence  Frequency  Varies with intake/fluid loss  5+ times a day  Nocturia  Renal disease  Enlarged prostate  Volume  Recent Changes  Symptoms of alterations  Urgency  Dysuria Urinary Elimination Faculty: S.Howell 30 Other factors… Health history Symptoms of alterations  Onset & duration  Precipitating /aggravating factors Incontinence Hesitancy Polyuria Oliguria Nocturia Dribbling Hematuria Retention Residual urine Urinary Elimination Faculty: S.Howell 31 Health History Continued Health history Factors Affecting Urination  Medical history Disease conditions Medication history  Surgical history  Catheter  Environmental barriers  Mobility- ability to perform ADL Urinary Elimination Faculty: S.Howell 32 Factors Influencing Urination  Urinary tract infections Commonly result from catheterization; may have other causes  Urinary incontinence …involuntary leakage of urine  Nocturia Waking at night to void; associated with aging, overactive bladder, circulatory problems, or prostate enlargement  Urinary retention An accumulation of urine due to the inability of the bladder to empty Absence of urine output over several hours, bladder distension, restlessness, diaphoresis, abdominal pain  Urinary diversions a urinary stoma, to divert urine to external source, i.e. abdominal surface Urinary Elimination Faculty: S.Howell 33 Urinary Elimination Faculty: S.Howell 34 Assessment of Urinary Status Physical Assessment Skin and mucus membranes Skin turgor  Flank Pain Distended bladder Discharge/inflammation/lesion Urinary Elimination Faculty: S.Howell 35 Physical Assessment (cont) Assessment of Urine Intake & output Characteristics of urine Color Pale, straw-colored to amber Bleeding- Meds can change urine color – (phenazopyridine- bright orange) Beets, and berries may turn the urine red Clarity  Transparent unless pathology is present Odor  Ammonia-like in nature Urinary Elimination Faculty: S.Howell 36 Quick Quiz! 2. When might a health care provider suspect that a patient is experiencing urinary retention? A. The patient indicates pain in the suprapubic region. B. The patient indicates spasms and difficulty during urination. C. The patient voids small amounts of urine two to three times per hour. D. The patient voids large amounts of foul- smelling, cloudy urine. Urinary Elimination Faculty: S.Howell 37 Urine Tests and Diagnostic Examinations Urinalysis Specific gravity Culture C&S Noninvasive examination Invasive examination Urinary Elimination Faculty: S.Howell 38 Urine Specimens URINALYSIS pH – 4.6 – 8.0  Reflects acid-base balance  Above 8 – alkaline – metabolic alkalosis,  overuse of alkalizing meds, UTI  Below 4.6 – acidic – metabolic acidosis,  uncontrolled diabetes, medications, high doses of Vitamin C  Glucose – abnormal  occurs after a heavy meal, emotional stress, or with glucose IVs  Ketones – abnormal –  uncontrolled diabetes, fasting, severe infection with nausea and vomiting, dehydration, starvation, excessive aspirin usage  Protein- abnormal  Bacteria- none  Blood – up to 2 RBC  WBC 0-4 Urinary Elimination Faculty: S.Howell 39 Urine Specimens Culture & Sensitivity Voided specimen – bacterial count of over 100,000 organisms/ml (infection) Sterile catheter specimen – over 10,000 organisms per mL Specific gravity 1.010-1.025 is the normal range measures the concentration of the urine Urinary Elimination Faculty: S.Howell 40 Diagnostic Tests Nursing responsibilities Obtain sample Arrange and ensure test is done Follow specific test protocols Monitor results Notify MD Implement actions based on results Health teaching Urinary Elimination Faculty: S.Howell 41 Urinalysis Routine –collected in urine specimen container (15-30 mL) Midstream- clean voided –collected in sterile urine specimen container 24 Hour Urine Collection- discard first void and then collect urine for 24 hr. Urinary Elimination Faculty: S.Howell 42 Urinary Elimination Faculty: S.Howell 43 Urinary Elimination Faculty: S.Howell 44 Urinary Elimination Faculty: S.Howell 45 Other Diagnostic Tests KUB C T scan Renal Ultrasound IVP Renal Scan Cystoscopy Renal angiogram Urinary Elimination Faculty: S.Howell 46 Alterations in Urinary Elimination Failure to store or to empty urine Causes- Impaired bladder function Obstruction to urine outflow Infection Inability to voluntarily control micturition Urinary Elimination Faculty: S.Howell 47 Urinary Tract Infections (UTIs) UTIs are responsible for more than 500,000 visits to Cdn drs. every year (Kidney Foundation of Canada) If left untx’d, can spread to kidneys, causing kidney infection (pyelonephritis) & possible long-term kidney damage Women are more susceptible than males to UTIs Why? Urinary Elimination Faculty: S.Howell 48 Etiology of UTIs Caused by many different micro-organisms  The most frequent cause is E.coli Often caused by staph Klebsiella, Proteus & Enterobacter are less common causes. (Hospital-acquired infections) Urinary Elimination Faculty: S.Howell 49 Alterations in Urinary Elimination Urinary Tract Infection Etiology E.Coli Bacteria enters up the urethra Women more susceptible to UTIs r/t short urethra and proximity of urethral meatus to anus. Pregnant women- decreased bladder emptying Residual urine Alkaline urine Obstructed catheter tubing Instrumentation of urinary tract Urinary Elimination Faculty: S.Howell 50 Alterations in Urinary Elimination Urinary Tract Infection Signs & Symptoms Cystitis (inflammation of the bladder) Dysuria Hematuria- blood-tinged urine Concentrated and cloudy urine r/t ↑ WBC Flank or lower back pain /tenderness Fever, chills Frequency Nausea, vomiting Malaise Note: can also by asymptomatic Urinary Elimination Faculty: S.Howell 51 Alterations in Urinary Elimination- Urinary Retention Urine accumulates in the bladder – inability to void, causing… Assessment Feelings of pressure Spasms, tenderness over the symphysis pubis Frequency with overflow voids of 25-50 mL with no relief (urethral sphincter is unable to hold back) Acute retention – no urine for several hours Urinary Elimination Faculty: S.Howell 52 Bladder Scanner Urinary Elimination Faculty: S.Howell 53 Bladder Scanner Urinary Elimination Faculty: S.Howell 54 Bacteriuria Bacteria in the urine Can lead to spread of organisms into kidneys (pyelonephritis) & bloodstream (bacteremia) Urinary Elimination Faculty: S.Howell 55 Urosepsis Bloodstream infection from UTI Urinary Elimination Faculty: S.Howell 56 Residual Urine Urine left in bladder after voiding Occurs when client can’t empty bladder, as left-over urine becomes alkaline & is an ideal site for growth of micro-organisms Urinary Elimination Faculty: S.Howell 57 Alterations in Urinary Elimination- Residual Urine Failure to store or to empty urine Causes- Impaired bladder function Obstruction to urine outflow Infection Inability to voluntarily control micturition Urinary Elimination Faculty: S.Howell 58 Nursing Diagnosis- urinary elimination Disturbed body image R/T urinary incontinence Pain (acute, chronic) Self-care deficit toileting Impaired skin integrity Impaired urinary elimination Urinary incontinence (transient, urge, stress, mixed) Urinary retention Urinary Elimination Faculty: S.Howell 59 Risk Factors for Women Sexual activity Pregnancy Diaphragm or spermicide use Uterine prolapse Urinary Elimination Faculty: S.Howell 60 Risk Factors for Men Instruments in urinary tract Congenital abnormalities Urinary Elimination Faculty: S.Howell 61 Clients at Increased Risk Older adults Antibiotic use Progressive underlying disease Decreased immunity Diabetes Urinary Elimination Faculty: S.Howell 62 Alterations in Urinary Elimination Urinary Incontinence Involuntary loss of urine  Functional Incontinence  Involuntary passage of urine in a client with intact urinary system. The patient has bladder control but unable to reach the toilet.  Change in environment, or physical function i.e. sensory, cognitive, or mobility deficits  Overflow Incontinence  Loss of a small amount of urine from an over distended bladder. Patient may feel like the bladder is never completely empty.  Drugs, fecal impaction, spinal cord injury enlarged prostate. Urinary Elimination Faculty: S.Howell 63 Urinary Incontinence Involuntary loss of urine It is a prevalent condition Huge psychosocial impact Urinary Elimination Faculty: S.Howell 64 Types of Incontinence Transient Urge Stress Mixed (stress & urge) Urinary Elimination Faculty: S.Howell 65 Types of Incontinence (con’t) Functional (see above slide) Total Neurogenic Bladder Dysfunction Urinary Elimination Faculty: S.Howell 66 Overactive Bladder Syndrome Involuntary bladder contractions S&S – urgency, frequency & nocturia Some have urge incontinence Often caused by nervous system disorders & outflow obstruction Can be aggravated by caffeinated beverages Urinary Elimination Faculty: S.Howell 67 Nocturia Waking at night to void Associated with: Aging overactive bladder enlarged prostate in men Peripheral edema Treatment Options - Reduce fluid intake in early evening - Elevate feet for 1 to 2 h before hs - Medications Urinary Elimination Faculty: S.Howell 68 Urinary Retention Marked accumulation of urine in bladder as a result of inability to empty bladder Urine collects in bladder, stretches its walls & causes pressure, discomfort, tenderness, restlessness & diaphoresis Can lead to overflow incontinence Frequency with overflow voids of 25-50 mL with no relief Voids 2-3 x/hr with little relief Urinary Elimination Faculty: S.Howell 69 S&S of Urinary Retention No output for several hrs. Bladder distension Restlessness Diaphoresis Abdominal discomfort Bladder can be stretched to hold 2000-3000 mL Urinary Elimination Faculty: S.Howell 70 Quick Quiz! 2. When might a health care provider suspect that a patient is experiencing urinary retention? A. The patient indicates pain in the suprapubic region. B. The patient indicates spasms and difficulty during urination. C. The patient voids small amounts of urine two to three times per hour. D. The patient voids large amounts of foul- smelling, cloudy urine. Urinary Elimination Faculty: S.Howell 71 Alterations in Urinary Elimination Urinary Incontinence Stress Incontinence  Leakage of small amounts of urine caused by sudden increase in intra-abdominal pressure  Urinary urgency and frequency  Weak musculature  Coughing, laughing, sneezing Urge incontinence  Involuntary passage of large amount of urine associated with urgency, frequency or nocturia  Caffeine, infection, large fluid intake Urinary Elimination Faculty: S.Howell 72 Alterations in Urinary Elimination Urinary Incontinence Mixed Stress and urge incontinence Transient Urine loss resulting from causes outside of/affecting the urinary system that resolve when the underlying cause is treated,  Dementia, delirium, infection, obstruction, limited mobility, emotional/psychological issues, Urinary Elimination Faculty: S.Howell 73 Alterations in Urinary Elimination Urinary Incontinence Reflex  Occurs at somewhat predictable intervals.  Unaware of full bladder and does not feel the urge to void, but the bladder empties spontaneously  Spinal cord injuries Total  continuous and unpredictable  Neurogenic Bladder Dysfunction Caused by underlying disease or disorder of the nervous system, such as a CVA, or spinal cord injury Urinary Elimination Faculty: S.Howell 74 Nursing Interventions: Urinary Elimination Assessment Bladder training Kegel’s exercises Intermittent catheterization Surgery medications Urinary Elimination Faculty: S.Howell 75 Nursing Interventions: Urinary Elimination Health promotion Client education  Hygiene  Symptoms of urinary alterations  Importance of fluids Urinary Elimination Faculty: S.Howell 76 Nursing Interventions: Urinary Elimination Health promotion Promoting regular voiding importance of regular voiding- q3-4h To maintain normal bladder capacity Assume normal position for voiding Males- standing position Sensory stimuli Maintain adequate fluid intake-1500 to 2000 mL Avoid bladder irritants Promote complete bladder emptying Prevent infection Urinary Elimination Faculty: S.Howell 77 Urinary Elimination Faculty: S.Howell 78 Nursing Interventions: Urinary Elimination Urinary Catheters Require physician order for catheter insertion. Types of catheters/ functions Intermittent Indwelling Suprapubic Condom Urinary Elimination Faculty: S.Howell 79 Urinary Elimination Faculty: S.Howell 80 Urinary Elimination Faculty: S.Howell 81 Suprapubic Catheter Can you still urinate normally with a suprapubic catheter? Urinary Elimination Faculty: S.Howell 82 Condom Catheter Urinary Elimination Faculty: S.Howell 83 Urinary Elimination Faculty: S.Howell 84 Urinary Elimination Faculty: S.Howell 85 Urinary Elimination Faculty: S.Howell 86 Continuous Bladder Irrigation Purpose Technique Urinary Elimination Faculty: S.Howell 87 Potential Sites of Infection Urinary Elimination Faculty: S.Howell 88 Nursing Interventions: Urinary Elimination Promote comfort Warm sitz bath Maintenance of skin integrity Wash perineal area with pH balanced soap and warm water to remove urine Provide dry linen Report skin alterations Use appropriate barrier creams/ointments Urinary Elimination Faculty: S.Howell 89 Urinary Diversions Ureterostomy – bringing the end of one or both ureters to abdominal surface Nephrostomy – tube placed directly into renal pelvis to provide urinary drainage Urinary Elimination Faculty: S.Howell 90 Urinary Elimination Faculty: S.Howell 91 Urinary Elimination Faculty: S.Howell 92 Urinary Elimination Faculty: S.Howell 93 Nursing Care Infection control & hygiene Consider growth & development Psychosocial & Cultural Considerations Urinary Elimination Faculty: S.Howell 94 Nursing Interventions: Urinary Catheters and Catheter Care Aseptic technique Push fluids, how much? Monitor urine Closed system Prevent backflow; kinks in tubing Maintain comfort Urinary Elimination Faculty: S.Howell 95 Collecting a Midstream Urine Sample, start urine, stop, collect ↑ Urinary Elimination Faculty: S.Howell 96 Urinary Elimination Faculty: S.Howell 97 Urinary Elimination Faculty: S.Howell 98 Implementation: Restorative Care Lifestyle modification Pelvic floor muscle exercises Bladder training Habit retraining and prompted voiding Self-catheterization Urinary Elimination Faculty: S.Howell 99 Nursing Interventions: Urinary Elimination Promote comfort Warm sitz bath Maintenance of skin integrity Wash perineal area with pH balanced soap and warm water to remove urine Provide dry linen Report skin alterations Use appropriate barrier creams/ointments Urinary Elimination Faculty: S.Howell 100 Nursing Diagnosis Urinary Incontinence Risk for infection Toileting self-care deficit Impaired urinary elimination Urinary retention Urinary Elimination Faculty: S.Howell 101 Client Education Proper perineal hygiene Symptoms of urinary alterations Fluid intake Urinary Elimination Faculty: S.Howell 102 Promoting Regular Micturition Regular patterns of urinary elimination Regular bowel movements Stimulate micturition reflex Maintain elimination habits Maintain adequate fluid intake Avoid foods/fluids that irritate the bladder Urinary Elimination Faculty: S.Howell 103 Promoting Complete Bladder Emptying Take time to void Try again once client feels they have emptied bladder Intermittent cath if needed Urinary Elimination Faculty: S.Howell 104 Preventing Infection Good perineal hygiene Proper technique Squirt bottle with warm water Maintaining adequate fluid intake Urinary Elimination Faculty: S.Howell 105 Restoring Bladder Control/ Promoting Continence Pelvic floor muscle exercises Voiding schedule Running water/stroking inner thigh Relaxation techniques Don’t ignore urge to void Minimize coffee, tea, alcohol Take diuretics in am Appropriate periods bt voiding Protective undergarments Wt control if needed Urinary Elimination Faculty: S.Howell 106 Evaluation- Urinary Elimination Evaluation Reassess the client’s urination pattern and signs and symptoms of alterations Inspect the character of the client’s urine Have the client and family demonstrate any self-care skills Have the client discuss feelings regarding any permanent changes in elimination Ask client if expectations are being met Urinary Elimination Faculty: S.Howell 107  5 Things you learnt today!!! NRSG 110 Faculty: Susan Howell 108 NRSG 110 Faculty: Susan Howell 109 NRSG 110 Faculty: Susan Howell 110