Unit 7.1 Elimination needs.pdf

Sri Rahaya Nafitri Abdul Razak (U6240037) 6. ELIMINATION: URINARY ELIMINATION INRODUCTION A person’s urinary habits depends on social culture, personal habits & physical abilities Physiology of Urinary Elimination Urinary elimination depends on the effective functioning of the upper urinary tra...

Sri Rahaya Nafitri Abdul Razak (U6240037) 6. ELIMINATION: URINARY ELIMINATION INRODUCTION A person’s urinary habits depends on social culture, personal habits & physical abilities Physiology of Urinary Elimination Urinary elimination depends on the effective functioning of the upper urinary tract’s kidneys, ureters & the lower urinary tract’s urinary bladder urethra & pelvic floor. Urination Micturition, voiding & urination – refer to – process of emptying – urinary bladder. Urine collects in – bladder until pressure stimulates sensory nerve endings in the bladder wall (stretch receptors). Adult bladder contains between 250-450mL – urine. Children considerably smaller volume, 50-200mL – urine, stimulates these nerves. Micturition Reflex  The micturition reflex process can be summarised as follows –  Filling of the urinary bladder  Stimulation of stretch receptors  Afferent impulses pass through the pelvic nerve and reach the spinal cord  Efferent impulses through the pelvic nerve  Contraction of the detrusor muscle and relaxation of the internal sphincter  The flow of urine into the urethra and stimulation of stretch receptors  Afferent impulses through the pelvic nerve  Inhibition of the external sphincter  Voiding of the urine or micturition Factors Affecting Voiding 1. Development Factors I. Infants  Gradually increase to 250-500mL during first year  Urine 20 times/day – without urinary control  Urine: colorless, odorless, specific gravity (SG) – 1.008 bcz of have immature kidney, unable to concentrate urine effectively  Develop control during 2 and 5 y/o, control during daytime, precedes night time control II. Preschoolers  Responsible for independent toileting III. School-Age Children  5-10 y/o  Enuresis: bed wetting; involuntary passing of urine in children after bladder control is achieved  Nocturnal enuresis/bed-wetting: involuntary urination at night IV. Older Adults  Excretory function of – kidney diminishes with age, disease process: e.g; arteriosclerosis, impairment – renal function, surgery, electrolyte imbalance, medication toxicity  Complaint of frequency of urination - Men – due – enlarged prostate gland - Women – due – weakened muscles support - bladder, urethral sphincter  Nocturnal frequency: the need for older adults to arise during the night to urinate 2. Psychosocial Factors  Privacy, normal position, sufficient time, occasionally, running water – may produce anxiety & muscle tension  The person is unable to relax abd & perineal muscle & external urethral sphincter, thus voiding is inhibited 3. Fluid and Food Intake  Caffeine (coffee, tea, cola drinks) – increase urine production  Food & fluids high in sodium can cause fluid retention  Food – e. g; beets(red)/carotene (yellower than usual) change colour of urine 4. Medication  Diuretics; chlorothiazide or furosemide(Lasix) – increase urine formation 5. Muscle Tone  Good muscle tone – to maintain stretch & contractility of detrusor muscle/pelvic muscle tone – bladder can fill adequately & empty completely  Retention catherter/continuous bladder drainage (CBD) use for poor bladder muscle tone 6. Pathologic Conditions  Renal failure, heart failure, urinary calculus(solid particle in urinary system), hypertrophy(enlargement of muscle or organ) – prostate gland – interfere – urine production 7. Surgical & Diagnostic Procedures  Cystoscopy, spinal anesthetics ALTERED URINE PRODUCTION i. Polyuria(diuresis): the production of large amounts of urine by the kidneys without an increase fluid intake  Can lead to intense thirst(polydipsia); usually happen to pt had DM, diabetes insipidus, chronic nephritis ii. Oliguria: low urine output iii. Anuria: lack of urine production ALTERED URINARY ELIMINATION i. Urinary frequency: the need to urinate often ii. Nocturia: voiding two or more times at night iii. Urgency to urine: the feeling that one must urinate iv. Dysuria: painful or difficult voiding v. Enuresis/bed-wetting; involuntary passing of urine in children after bladder control is achieved vi. Urinary incontinence: a temporary or permanent inability of the external sphincter muscles to control the flow of urine from the bladder a) Stress urinary incontinence: involuntary, sudden loss of urine secondary to increased intraabdominal pressure that is bothersome or affecting the patient's quality of life. Physical activities precipitating SUI include laughing, sneezing, straining, coughing, or exercising b) Urge urinary incontinence: sudden, intense urge to urinate followed by an involuntary loss of urine c) Mixed urinary incontinence: symptoms when stress UI and urgency UI are present d) Overflow urinary incontinence: involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction vii. Urinary Retention: a condition in which you are unable to empty all the urine from your bladder. Average Daily Urine Output by Age NURSING MANAGEMENT 1. Assessing i. Nursing history  Voiding pattern, frequency, appearance of urine, any recent changes, any past/current problems with urination ii. Physical assessment  Percussion of – kidneys to detect areas of tenderness  Palpation & percussion of bladder  Inspect urethral meatus of male & female pt – swelling, discharge, inflammation  Skin color, texture, tissue tugor is presence edema  Urine incontinence, dribbling, dysuria noted in history, skin of perineum inspected for irritation bcz contact with urine can excoriate skin iii. Assessing urine  iv. Measuring urinary output  Normally, adult: urine output @ 60mL/h or about 1500mL/day; factor affected fluid intake; perspiration and breathing or diarrhea, cardiovascular, renal status of individual  Urine output below 30 mL/h may indicate low blood volume/ kidney malfunction To measure urine output 1. Wear glove – prevent infection/blood in urine 2. Ask – pt. void – a clean urinal / bedpan/commode, toilet collection device “hat” 3. Instruct – to keep urine separate from feces, avoid putting toilet paper in the urine collection container 4. Pour – into calibrated container. 5. Read – urine measurement – eye level. 6. Rinse – container. 7. Remove glove & - hand hygiene 8. Record in output To measure urine from urinary catheter 1. Apply glove 2. Place the container under – spout -urine bag 3. Open – spout & permit – urine to flow into – container. 4. Close – spout 5. Step 5 – 8 follow as above 2. Diagnostic Tests  Blood Test : Blood Urea Nitrogen (BUN)   24 hrs urine collection : Creatinine Clearance  Collecting urine specimens, measuring specific gravity NURSING INTERVENTION A. Maintaining Normal Urinary Elimination i. Promoting Fluid intake  Increase fluid intake increase urine production, stimulates the micturition reflex; normal daily intake 1500mL for normal adult  Higher daily fluid intake, ex: perspiring excessively (have diaphoresis), experiencing abnormal fluid losses; vomiting, gastric suction, diarrhea, wound drainage  Pt had UTI or urinary calculi (stones) should consume 2000 to 3000 mL of fluid daily to dilute the urine ii. Maintaining Normal Voiding Habits iii. Assisting with toileting  Nurse should assist to prevent fall  Bathroom should contain easily accessible call signal to summon help  Encourage pt to use handrails placed near the toilet  Provide equipment close to bed; urinal, bedpan,commode B. Preventing Urinary Tract Infections i. Fluid intake ii. Hygiene - Women usually got the UTI cause the shorter urethra and its proximity to the anal and vaginal area; bacteria (Escherichia Coli) - These gastrointestinal bacteria can colonize the perineal area and move into the urethra, especially when urethral trauma, irritation, manipulation  Drink eight 8-ounce glasses of water per day to flush bacteria out of the urinary system  Practice frequent voiding (every 2 to 4 hrs) to flush bacteria out of the urethra and prevent organism from ascending into the bladder. Void immediately after intercourse  Avoid use of harsh soaps, bubble bath, powder or sprays in the perineal area. these substances can be irritating to the urethra and encourage inflammation and bacterial infection  Avoid tight-fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area  Wear cotton rather than nylon underclothes. Accumulation of perineal moisture facilitates bacterial growth. Cotton enhances ventilation of the perineal area  Girls and women should always wipe the perineal from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra  If recurrent urinary infections are a problem, take showers rather than baths. Bacteria present in bath water can readily enter the urethra C. Managing Urinary Incontinence i. Continence (Bladder) Retraining ii. Pelvic floor muscle exercise (Kegels) iii. Maintaining Skin Integrity - Skin is that continually moist becomes macerated (softened) - Urine that accumulates on the skin is converted to ammonia, irritate the skin - Bcz both skin irritation and maceration predispose pt to skin breakdown and ulceration, the incontinencent person requires meticulous skin care - Nurse should washes pt’s perineal area with mild soap & water or prepare no-rinse cleanser after episodes of incontinence - Rise the area thoroughly if soap and water were used - Dries it gently n thoroughly - Clean, dry clothing/bed linen should be provided - Nurses apply barrier ointments/creams to protect the skin from contact with urine - Pad the pt’s clothes for protection, nurse should use products that absorb wetness & leave a dry surface in contact with skin - Use drawsheet, it does not stick to the skin when wet, decreases the risk of bedsores and reduces odor