CHAPTER 45 URINARY ELIMINATION

OBJECTIVE 1: DESCRIBE THE PROCESS OF ELIMINTATION

When the urinary system fails to function all other organ systems are affected.

Kidneys remove waste from the blood to form urine. Ureters transport the urine from the kidneys to the

bladder. The bladder holds the urine until the urge to urinate is developed. Urine leaves the bladder

through the urethra. Normal urine output for an adult is 1500ml-1600ml per day. Less than 30ml/hr

indicates a problem in renal function.

Kidneys lie on either side of the vertebral column with the left being higher than the right. 20-25% of the

cardiac output circulates each minute through the kidneys. The Nephron is the functional unit of the

kidney’s and forms urine. Nephron has 7 parts glomerulus (initial site of filtration and a tuft of

capillaries), Bowmen’s capsule where all the filtrated material goes into. Large proteins cannot be

filtered if protein in the urine it is called proteinuria and results from damage to the glomerulus. The

glomerulus filters about 125ml of filtrate per minute 99% is reabsorbed into plasma the other 1% is

excreted as urine. Kidneys produce erythropoietin which functions within the bone marrow and to

stimulate RBC production and maturation, without this a person is prone to anemia. In times of renal

ischemia (decreased blood supply) renin is released from juxtaglomerular cells which is an enzyme that

converts angiotensinogen (from the liver) to angiotensin 1 which is converted to angiotension2 (in the

lungs) Angiotensin 2 stimulates aldosterone and release from the adrenal cortex which in turn causes

retention of water through vasoconstriction. Prostaglandin and prostacyclin causes vasodilation and

increase arterial b/p and renal blood flow. Kidneys are important to calcium and phosphate regulation, it

produces a substance that converts vit D to active form, Clients with poor renal function prone to

develop renal bone disease from demineralized bone because of impaired calcium absorption.

*Decreased blood>renin release>converts angiotensinogen to angiotensin 1>converted to AN 2 in lungs

This stimulates aldosterone released from adrenal cortex and causes water retention.

Ureters= tubule structures that enter the bladder. This urine is normally sterile. Peristaltic waves cause

urine to enter the bladder in spurts. Because the ureters enter the bladder from the posterior wall this

prevents the urine from going back up the ureters during the act of micturition-compression of the

ureter at the ureterovesical junction-(ureters with bladder). Kidney stone=renal calculi. Peristaltic pain

resulting in strong peristaltic waves that cause pain= renal colic.

Bladder

Stores urine. When empty lies in the pelvic cavity behind the symphysis pubis. In men= against the

anterior wall of the rectum. In women= anterior wall of the uterus and vagina. When full it expands

above the symphysis pubis, greatly distended can reach to umbilicus. Pregnant woman fetus pushes

against the bladder resulting in a feeling of fullness 1st and 3rd trimester. Trigone= triangular area on the

inner surface of the bladder and is at the base of the bladder. Opening at three areas, two for ureters

and one for the urethra. Holds 600ml of urine. Desire to urinate in adults 150-200ml and in children 50-

100ml.

Urethra-Passes through the outside of the body through urethral meatus and descends through muscles

called the pelvic floor muscles, when contracted it prevents urination. In women the urethra is 1 ½ to 2

½ inches, shortness predisposes women to infection. In men 8 inches long has three sections: prostatic

urethra, membranous urethra and penile urethra. External sphincter permits voluntary flow of urine.

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OBJECTIVE 1: DESCRIBE THE PROCESS OF ELIMINTATION

When the urinary system fails to function all other organ systems are affected. Kidneys remove waste from the blood to form urine. Ureters transport the urine from the kidneys to the bladder. The bladder holds the urine until the urge to urinate is developed. Urine leaves the bladder through the urethra. Normal urine output for an adult is 1500ml-1600ml per day. Less than 30ml/hr indicates a problem in renal function. Kidney s lie on either side of the vertebral column with the left being higher than the right. 20-25% of the cardiac output circulates each minute through the kidneys. The Nephron is the functional unit of the kidney’s and forms urine. Nephron has 7 parts glomerulus (initial site of filtration and a tuft of capillaries), Bowmen’s capsule where all the filtrated material goes into. Large proteins cannot be filtered if protein in the urine it is called proteinuria and results from damage to the glomerulus. The glomerulus filters about 125ml of filtrate per minute 99% is reabsorbed into plasma the other 1% is excreted as urine. Kidneys produce erythropoietin which functions within the bone marrow and to stimulate RBC production and maturation, without this a person is prone to anemia. In times of renal ischemia (decreased blood supply) renin is released from juxtaglomerular cells which is an enzyme that converts angiotensinogen (from the liver) to angiotensin 1 which is converted to angiotension2 (in the lungs) Angiotensin 2 stimulates aldosterone and release from the adrenal cortex which in turn causes retention of water through vasoconstriction. Prostaglandin and prostacyclin causes vasodilation and increase arterial b/p and renal blood flow. Kidneys are important to calcium and phosphate regulation, it produces a substance that converts vit D to active form, Clients with poor renal function prone to develop renal bone disease from demineralized bone because of impaired calcium absorption. *Decreased blood>renin release>converts angiotensinogen to angiotensin 1>converted to AN 2 in lungs This stimulates aldosterone released from adrenal cortex and causes water retention. Ureters = tubule structures that enter the bladder. This urine is normally sterile. Peristaltic waves cause urine to enter the bladder in spurts. Because the ureters enter the bladder from the posterior wall this prevents the urine from going back up the ureters during the act of micturition-compression of the ureter at the ureterovesical junction-(ureters with bladder). Kidney stone= renal calculi. Peristaltic pain resulting in strong peristaltic waves that cause pain= renal colic. Bladder Stores urine. When empty lies in the pelvic cavity behind the symphysis pubis. In men= against the anterior wall of the rectum. In women= anterior wall of the uterus and vagina. When full it expands above the symphysis pubis, greatly distended can reach to umbilicus. Pregnant woman fetus pushes against the bladder resulting in a feeling of fullness 1st^ and 3rd^ trimester. Trigone= triangular area on the inner surface of the bladder and is at the base of the bladder. Opening at three areas, two for ureters and one for the urethra. Holds 600ml of urine. Desire to urinate in adults 150-200ml and in children 50- 100ml. Urethra- Passes through the outside of the body through urethral meatus and descends through muscles called the pelvic floor muscles, when contracted it prevents urination. In women the urethra is 1 ½ to 2 ½ inches, shortness predisposes women to infection. In men 8 inches long has three sections: prostatic urethra, membranous urethra and penile urethra. External sphincter permits voluntary flow of urine.

Act of urination: The brain influences bladder function. Cerebral cortex, thalamus, hypothalamus and brain stem are all included in allowing the urge to void and not allow. As bladder volume increases the walls stretch sending sensory impulses to the micturition center of the sacral spinal cord. Because u can ignore this urge with the same impulses urination is under voluntary control. External sphincter remains contracted no urination- if relaxed-the micturition reflex stimulates the detrusor muscle to contract and urination occurs. Reflux incontinence =Damage to the spinal cord above the sacral region causes loss of voluntary control of urination, but the micturition reflex remains intact and a person loses the sensation to void. Retention occurs when a chronic obstruction (prostate enlargement) hinders bladder emptying causing micturition reflex to change this leads to bladder over activity and the bladder does not completely empties. Objective 2: factors influencing elimination. Disease affects renal function, urine elimination or changes in urine volume or quality, and is classified as prerenal (decreased blood flow to and through the kidneys), renal (diseased conditions of renal tissue) or postrenal (obstruction in the lower urinary tract). Some renal problems are acute and reversible (UTI), others are chronic and irreversible (Renal dysfunction). Many diseases affect the ability of a person to micturate. DM and multiple sclerosis causes a change in nerve functions that fan lead to loss of bladder tone, inability to sense fullness and bladder contractions. Benign prostatic hyperplasia (BPH) = affects older men and are prone to urinary retention and incontinence. Alzheimer’s disease- loses ability to sense fullness or remember procedure for voiding. DJD (degenerative joint disorder) or Parkinson’s makes it difficult for patients to get to the bathroom. ESRD (end stage renal disease) is irreversible has symptoms of uremic syndrome (and increase in nitrogenous waste in the blood, fluid and electrolyte imbalances, vomiting, headache, nausea, ect (p1132). Dialysis and organ transplant Dialysis- has two types. Peritoneal and hemodialysis Peritoneal dialysis is an indirect method of cleaning the blood through osmosis and diffusion. The peritoneum functions as a semipermeable membrane. The solution (dialysate) is infused into the patient’s peritoneal cavity (like the abdomen) through a surgically placed catheter. Gravity drains out the solution bringing the waste products with it. Hemodialysis (remember hemo means blood)- A machine with an artificial kidney that is semipermeable removes accumulated waste from the blood. In the machine one side has the dialysate solution and the patients’ blood passes through the other side. The process of diffusion osmosis and ultrafiltration cleans the blood and then it returns to the patient through a special port called a Gore text graft, artierovenous fistula or hemodialysis catheter. Organ transplant- is the transfer of the disease kidney with a healthy one from a human donor or a cadaver with compatible blood and tissue type. Immunosuppressive medications are needed for the rest of the person’s life to prevent the body from rejecting the kidney. Unlike the other alternatives this method offers the client potential for normal kidney functions.

Urinary diversion= permanent or temporary bypass of bladder and urethra as the exit routes for urine. Permanent= bladder cancer. The client with a urinary diversion has a stoma( artificial opening) on the abdomen to drain urine. Urinary retention = accumulation of urine due to the bladder inability to empty. When the bladder stretches it triggers the micturition reflex to allow the patient the ability to know the bladder is full and go and void. When the bladder does not respond to this reflex the bladder begins to retain urine causing a feeling of pain and restlessness. Retention with overflow develops. The sphincter allows 25-60ml or urine to leave in effort to relieve the built in pressure from retention and regain control. The client may void 2-3 times per hour with nor real relief or may dribble urine continually. Watch for frequent urination and amount in your patient, also assess for distention and tenderness of the abdomen and anuria for several hours. In urinary retention the bladder can hold up to 2000-3000ml. it occurs as a result to obstruction, childbirth trauma, surgery, medications, anxiety, and alterations of the bladder. UTI= most common nosocomial infection (health care associated). Result from catherizations or surgical manipulation. Most common bacteria that cause UTI’s is Escherichia coli.75-95%. Bacteriuria=bacteria in the urine. Leads to bacteria in the kidneys and possibly leads to bacteremia or urospesis=bacteria in the blood stream. Bacteria enter through the ascending urethral route, inhabiting the distal urethra and external genitalia. Women are more susceptible than men because of the short urethra. Mens are less susceptible because of the length of the urethra but are more at risk for infection related renal disease. Older adults and clients with disease are also at risk. Residual (retained) urine is more alkaline and is a ideal reservoir for microorganisms. Urinary retention increases the risk of UTI. Poor perineal hygiene is another cause of UTI, especially in women, frequent sex and failure to wipe from front to back. Clients with pain or burning during urination= dysuria. an irritated bladder= cystitis. Blood in the urine= hematuria. Urine is cloudy due to WBC’s and bacteria in the urine, normally transparent. (on test). Infection to the upper urinary tract= pyelonephritis. Urinary incontinence: involuntary leakage of urine. Stress or urge incontinence 15-30% women. 50% of nursing home residents. 30% of adults at home. Continued incontinence increases the chances of skin breakdown, for those who are immobile pressure ulcers. Diversions Some patients have a urinary stoma that directs the flow of urine form the kidneys to the abdomen. The client with an incontinent urinary diversion with a ileal conduit wears a stoma pouch to collect urine there is no sphincter to control urine flow. Local irritation and skin breakdown occurs when urine has constant contact with skin. Downside-if urine flow is obstructed, irreversible damage to the kidneys occurs secondary to chronic infections or hydronephrosis. Nephrostomy=tube placed directly into the renal pelvis. These patients need referral to an ostomy nurse.

Nursing knowledge: Whether the patient has an actual or potential urinary problem, be sensitive to the clients elimination needs. You will need knowledge of concepts beyond anatomy and physiology of the urinary system to give appropriate care and need to understand infection control principles, hygiene measures, growth and development psychosocial influences. Infection control: the urinary tract is sterile. Use infection control principles to not pass on UTI’s apply knowledge of medical and surgical asepsis when involving care of genitals and urinary tract. Catheterization requires sterile technique. Perineal or exam of the genital area requires medical asepsis. Growth and Development: determine the patient’s ability to control urination over the life span. Infants and young children cannot concentrate urine and excretes large amounts of urine, example 6month old 13-18lbs secretes 400-500ml per day. 2-3 year olds are able to associate the sensations of bladder filling and urinations once they are able to control the external sphincter then toilet training can begin. Daytime control occurs before nighttime control. Accidents may happen in the day or night. Nocturnal enuresis -bed wetting. During pregnancy urinary frequency is common and increase in to UTI susceptibility. Repeated deliveries and hormonal changes result in decreased perineal muscle tone and contribute to urgency and stress incontinence. Aging also contributes, in men prostate enlargement begins during the 40’s and continues throughout life, resulting in urinary frequency and retention. In women changes in mucosa associated with hormones and menopause contribute to increase UTI. Changes in kidney and bladder function occur with aging .Concentrated urine declines. The older adult often experience Nocturia and often retain urine after voiding= residual urine. Increase the risk of UTI. Weak abdominal and pelvic floor muscles impair the ability of the sphincter to maintain tone during increased abdominal pressure. Gender can influence’s position of urination. Men stand females sit. Place clients in a position of comfort. If the patient prefers privacy try to prevent interruptions as the client voids. Some cultures women are so embarrassed about their urinary problem and won’t seek help. Some cultures women refuse to sit on toilets and prefer to squat rather than sit. Culture dictates when and where it is appropriate to urinate or if a male is able to take care of the urinary needs of a female client of if gender-congruent care is needed. Nursing process-Alterations in Urinary function: Assessment- gathers nursing history for the clients’ urination pattern, symptoms and factors affecting urination  patterns of urination(how frequent, normal amount and recent changes)  symptoms or urinary alterations,  Factors affection urination (age, meds, and environmental, physical conditions). Conduct physical assessment of the clients body systems potentially affected by urinary change.  Provides data to determine presence of elimination problems

chair or specimen hat is normally effective. You will need special devices for infants or toddlers not toilet trained. Use clear plastic, single use bags with self-adhering material over the child’s urethral meatus. Do not obtain specimens by squeezing the diaper…… duh!!!  Common urine test

Urinalysis a. Examine the specimen as soon as possible, preferable within 2 hours b. Make sure it is the first voided specimen in the am to ensure concentration. c. For quick screening perform certain portions of urinalysis with special reagent strips. Dip the strip them look for color change.  Specific gravity
The weight or degree of concentration of a substance compared with an equal volume of water.
Osmolality test measures the total number of particles in a solution.
Some nurses in critical care units are responsible for specific gravity testing.  Urine culture
Requires a sterile or clean voided sample of urine.
Takes 24-48 hours before the lab can report bacterial growth.
Broad spectrum antibiotic is sometimes ordered as a culture is obtained. a. The test for sensitivity determines which specific antibiotic is affective.
This result may show another antibiotic would be more effective. Diagnostic exams : two approaches for visualization of urinary structures are direct or indirect exams of the urinary system and then further divided into invasive and noninvasive categories table 45-4. Nursing responsibilities related to diagnostic examination.  Obtain a signed consent  Assessing patient for allergy to shellfish (iodine) which predicts allergy to dye used in certain studies like (intravenous pyelogram ( ivp) and renal arteriogram.  Administering bowel cleaning meds  Clients receive appropriate pre-test diet, NPO (Nothing by mouth), clear liquids. After the study  assess I and O’s  observe characteristics of urine (color, clarity and presence of blood)  encouraging fluid intake especially during radiopaque dye

Nursing Diagnosis: nursing diagnosis common to urination elimination are as follows  disturbed body image  urinary incontinence (functional ,stress , urge)  pain (acute, chronic)  Risk for infection  toileting self-care deficit  impaired skin integrity  impaired urinary elimination  urinary retention Planning: need to include realistic and individual goals and relevant outcomes. The nurse and client need to come up with goals and choose nursing interventions. Goals can be short term and long term. Example: “client will have normal voiding with complete bladder emptying within 24 hours”  client will void in 8 hours  urinary output of 300ml will occur with each voiding  clients bladder is not distended to palpation setting priorities  recognize the primary health problem and its influence on other problems  management of incontinence helps to more than one nurses diagnosis  Attention to the clients perceived needs is the most satisfactory and successful approach to accomplishing all goals.  Reinforcement of good health habits that are already followed improves compliance. Collaborative care The plan of care incorporates health promotion and therapeutic interventions individualized to client’s needs. Consider home environment and normal elimination routines when planning therapies. Exploe the need for health care referral’s and home health service. The clients plan requires multiple interventions, Implementation The action phase of the nursing process. Complete independent and collaborative interventions to assist in achieving the desired outcomes and goals. Independent activities are those where the nurse uses their own judgments. (teachings). Collaborative activities are those prescribed by the health care provider and carried out by the nurse, medication administration. Health promotion:  Client education  Promoting normal micturition

 For patient with bladder infection antibiotic or antiseptic irrigation solution is needed. Catheter insertion-see 45- Removal see page Alternatives to urethral catheterizations:  Suprapubic catheterizations-surgical placement through abdominal wall  Condom catheter of Texas catheter- placed on the penis Restorative care  Strengthening pelvic floor muscles- Pelvic floor exercises or Kegal excercises. Stress incontinence, overactive bladder and mixed causes of urinary incontinence.  Bladder retraining-reduces the voiding frequency and increase bladder capacity. Ignore and suppress the urge.  Habit training-helps improve voluntary control over urination, establishing a flexible toilet schedule.  Self- catheterization-4-6 times per day and volumes of 400-500ml  Maintenance of skin integrity-skin becomes alkaline and fosters skin breakdown. Wash with mild soap and warm water is the best way to remove urine from the skin. Lotion provides moisture and Vaseline acts as a barrier to urine.  Clients who wet their clothes need partial baths and dry clothing after voiding.  When skin becomes inflamed the care provider will prescribe a cream or spray with steroids to reduce inflammation.  Promotion of comfort-clean, dry clothing for client, protective pad for incontinent patient, urinary medications ( see p 1171)  Drink large amounts of water to prevent toxicity from sulfonamides and maintain optimal flow through urinary system.  If patient has an inflamed urethra-warm sitz bath for pain relief  Clients cannot relive pain from distention unless they release the bladder. Evaluation: the client is the best source of evaluation for outcomes and responses to nursing care. Also evaluate effectiveness of nursing interventions through comparisons with outcome goals. Evaluate for changes in voiding pattern and continued presence of urinary tract alteration. Actual outcomes are compared with expected outcomes`

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Download Lecture Notes on Urinary Elimination | and more Study notes Nursing in PDF only on Docsity!

OBJECTIVE 1: DESCRIBE THE PROCESS OF ELIMINTATION