Transcript Urinary elimination

URINARY ELIMINATION
Chapter 45
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A&P REVIEW

KIDNEYS


REMOVE WASTE FROM THE BLOOD TO
FORM URINE
URETERS

TRANSPORT URINE FROM THE KIDNEYS
TO THE BLADDER
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A&P REVIEW

BLADDER


RESERVOIR FOR URINE UNTIL THE URGE
TO URINATE DEVELOPS
URETHRA

URINE TRAVELS FROM THE BLADDER AND
EXITS THROUGH THE URETHRAL MEATUS
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KIDNEY FUNCTION


FILTER WASTE FROM THE BLOOD
PRODUCE SUBSTANCES THAT FORM
RED BLOOD CELLS
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
ERYTHROPOIETIN
FLUID AND ELECTROLYTE BALANCE
BLOOD PRESSURE CONTROL

RENIN-ANGIOTENSIN-ALDOSTERONE
SYSTEM
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PHYSIOLOGY OF
URINATION

BRAIN STRUCTURES THAT INFLUENCE
BLADDER EMPTYING

CEREBRAL CORTEX, THALAMUS,
HYPOTHALAMUS, BRAIN STEM

NORMAL VOIDING INVOLVES
CONTRACTION OF THE BLADDER
MUSCLES AND RELAXATION OF THE
URETHRAL SPHINCTER
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PHYSIOLOGY OF URINATION

FACTORS INFLUENCING URINATION

AMOUNT OF URINE IN BLADDER
ADULT NORMALLY HOLDS 600ML
 CHILD 150 – 200ML

INCREASING URINE VOLUME STIMULATES
THE MICTURATION CENTER IN THE
SPINAL CORD
 NORMALLY VOIDING IS A VOLUNTARY
PROCESS
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FACTORS THAT INFLUENCE
URINATION
 PRERENAL
 DECREASED
BLOOD FLOW TO AND
THROUGH THE KIDNEYS
 RENAL
 DISEASE
CONDITIONS OF THE RENAL
TISSUE
 POSTRENAL
 OBSTRUCTION
IN THE LOWER URINARY
TRACT
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DISEASES/ CONDITIONS THAT
INFLUENCE URINATION
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
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DIABETES – nerve and perfusion changes
MULTIPLE SCLEROSIS – nerve changes
BPH – BENIGN PROSTATIC
HYPERPLASIA - retention
COGNITIVE DISORDERS


ALZHEIMER’S DISEASE – sensation, cognitive
END-STAGE RENAL DISEASE – waste
buildup, F & E imbalance [uremic syndrome]

REQUIRES DIALYSIS OR TRANSPLANT
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OTHER FACTORS THAT
INFLUENCE URINATION
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SOCIOCULTURAL FACTORS
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PSYCHOLOGICAL FACTORS
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PRIVACY
ANXIETY
FLUID BALANCE
SURGICAL PROCEDURES
MEDICATIONS
DIAGNOSTIC EXAMINATION
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Squat toilet – common in Asia,
India
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TERMINOLOGY TO KNOW
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NOCTURIA
POLYURIA
OLIGURIA
DYSURIA
ANURIA
DIURESIS
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CYSTITIS
HEMATURIA
PYLONEPHRITIS
INCONTINENCE
NOCTURNAL
ENURESIS
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ALTERATIONS IN URINARY
ELIMINATION

URINARY RETENTION

ACCUMULATION OF URINE RESULTING
FROM AN INABILITY OF THE BLADDER TO
EMPTY PROPERLY

BLADDER UNABLE TO RESPOND TO THE
MICTURATION REFLEX
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ALTERATIONS IN URINARY
ELIMINATION

Urinary Retention

POSSIBLE CAUSES:

URETHRAL OBSTRUCTION
SURGICAL TRAUMA
 CHILD BIRTH
 ALTERATIONS IN SENSORY INNERVATION
 ANXIETY
 SIDE EFFECTS OF MEDICATIONS

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ALTERATIONS IN URINARY
ELIMINATION

URINARY TRACT INFECTIONS (UTIs)

MOST COMMON HEALTH CARE
ASSOCIATED INFECTION
CATHETERIZATION
 SURGICAL MANIPULATION
 75% – 95% CAUSED BY ECOLI
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ALTERATIONS IN URINARY
ELIMINATION
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UTI’s - causes
ANY CONDITION RESULTING IN
URINARY RETENTION (BPH,
swelling/trauma to urethra OR kinked,
obstructed or clamped catheter) INCREASES
THE RISK OF BLADDER INFECTION
Indwelling catheter [Foley] is a leading cause of
UTI and sepsis
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ALTERATIONS IN URINARY
ELIMINATION
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URINARY INCONTINENCE
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INVOLUNTARY URINATION
CAUSES

AGING
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50% OF ALL LONG TERM CARE RESIDENTS
SUFFER FROM INCONTINENCE
COMPLICATIONS

SKIN BREAKDOWN
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ALTERATIONS IN URINARY
ELIMINATION

URINARY DIVERSION
DIVERT URETERS TO ABDOMINAL STOMA
 CAUSES

CANCER OF THE BLADDER
 TRAUMA
 RADIATION
 CHRONIC CYSTITIS
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NEPHROSTOMY
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ILEAL CONDUIT
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Renal Replacement Therapy

Dialysis – can be short or long term
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Peritoneal Dialysis:
Indirect; uses osmosis and diffusion
 Peritoneum used as semi permeable membrane
 Sterile solution [dialysate] instilled into peritoneum by
gravity, left for a time, drained out


Hemodialysis
Mechanical filtering of blood via membrane
 Blood exits and returns via A/V fistula, CVL
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Renal Replacement Therapy

Kidney Transplant
Only ‘cure’ – can bring normal kidney function
 Living or cadaver donor organ
 Piggybacked into abdomen
 Requires immunosuppressant medication
 Family donation common
 Surgery may be more challenging for donor
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NORMAL V. ABNORMAL
URINE
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NORMAL URINE
VALUES
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APPEARANCE: clear
COLOR: Straw/ Yellow
to light amber
ODOR: slight ammonia
pH: 4.6 – 7.8
PROTEIN: 0 mg/dl
SPECIFIC GRAVITY:
1.010 – 1.035
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LEUKOCYTES:
NEGATIVE
NITRITES:
NEGATIVE
KETONES:
NEGATIVE
CRYSTALS:
NEGATIVE
GLUCOSE:
NEGATIVE
RBC: NEGATIVE
WBC: NEGATIVE
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ABNORMAL FINDINGS:
Implications

INCREASED Urine pH
RESPIRATORY OR METABOLIC ALKALOSIS
 GASTRIC SUCTION
 VOMITING
 URINARY TRACT INFECTION


DECREASED pH
METABOLIC ACIDOSIS
 DIABETES
 DIARRHEA
 RESPIRATORY ACIDOSIS
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ABNORMAL FINDINGS:
Implications

INCREASED PROTEIN
DIABETES
 CHRONIC HEART FAILURE
 PREECLAMPSIA
 GLOMERULONEPHRITIS
 POLYCYSTIC DISEASE
 LUPUS ERYTHEMATOUS
 HEAVY-METAL POISONING
 BLADDER TUMOR
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ABNORMAL FINDINGS:
Implications

INCREASED SPECIFIC GRAVITY
[concentrated]
DEHYDRATION
 GLYCOSURIA, PROTEINURIA
 FEVER
 VOMITING
 DIARRHEA


DECREASED SPECIFIC GRAVITY [dilute]
OVERHYDRATION
 RENAL FAILURE
 HYPOTHERMIA
 PYELONEPHRITIS
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ABNORMAL FINDINGS:
Implications

INCREASED RED BLOOD CELLS
GLOMERULONEPHRITIS
 ACUTE TUBULAR NECROSIS
 CYSTITIS
 TRAUMATIC BLADDER CATHETERIZATION


INCREASED WHITE BLOOD CELLS
BACTERIAL INFECTION IN THE URINARY
TRACT
 GLOMERULONEPHRITIS
 ACUTE PYELONEPHRITIS
 LUPUS

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INFECTION CONTROL AND
HYGIENE

THE URINARY TRACT IS A STERILE
ENVIRONMENT
APPLY KNOWLEDGE OF MEDICAL AND
SURGICAL ASEPSIS WHEN PROVIDING
CARE INVOLVING THE URINARY TRACT
 CATHETERIZATION IS A STERILE
TECHNIQUE
 PERINEAL CARE AND CATHETER CARE IS A
CLEAN PROCEDURE
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PSYCHOSOCIAL
CONSIDERATIONS

GENDER DIFFERENCES
MALES STAND TO URINATE
 FEMALES SIT TO URINATE
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HOW MANY PEOPLE LIE DOWN TO URINATE??
Culture variations
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Privacy, position [squat/sit/stand], gender congruity
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COMMON URINARY
ALTERATIONS
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URGENCY
FREQUENCY
HESITANCY
RETENTION
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DRIBBLING
INCONTINENCE
RESIDUAL URINE
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DIAGNOSTIC EXAMINATIONS
OF THE URINARY SYSTEM

OBTAINING A URINE SPECIMEN
RANDOM
 CLEAN CATCH (MIDSTREAM)
 STERILE
 TIMED COLLECTION
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DIAGNOSTIC EXAMINATIONS OF
THE URINARY SYSTEM

TESTING THE URINE
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CHEMICAL REAGENT STRIP (DIP STICK)
 BEDSIDE URINALYSIS
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pH
GLUCOSE
BLOOD
KETONES
PROTEIN
Follow instructions [timed]
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DIAGNOSTIC EXAMINATIONS OF
THE URINARY SYSTEM

TESTING THE URINE

STERILE SPECIMEN
STRAIGHT CATHETER
 ASPIRATE FROM INDWELLING CATHETER
 SAME PROCEDURE FROM URINARY DIVERSION


TIMED SPECIMEN TO BE SENT TO LAB

EXAMPLE: 24 HOUR URINE FOR UUN (URINE
UREA NITROGEN)
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SPECIAL CONTAINER
MUST SAVE ALL URINE OR START OVER
ICE
PRESERVATIVE
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NURSING IMPLICATIONS

CLEAN CATCH OR MIDSTREAM

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ASSEMBLE EQUIPMENT AND INSTRUCT
PATIENT ON TECHNIQUE TO OBTAIN
SPECIMEN
STRAIGHT CATH
ASSEMBLE EQUIPMENT
 EXPLAIN PROCEDURE TO PATIENT
 INSERT CATHETER USING STERILE
TECHNIQUE
 SEND OBTAINED SPECIMEN TO LAB IN
STERILE CONTAINER [5-10ml]
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NURSING IMPLICATIONS

OBTAINING STERILE SPECIMEN FROM
EXISTING URINARY CATHETER
Clamp catheter for 30 min prior to aspiration to
allow fresh urine to gather in tubing
 Disinfect access port
 Using syringe [10-15 ml] and large bore needle,
access collection port and withdraw 5- 10 ml urine;
label, double bag and send to lab
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

Newer catheters have needleless access [Luerlock]
May need to change Foley to get true sample
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NURSING IMPLICATIONS

NON-INVASIVE EXAMINATION OF THE
BLADDER AND KIDNEYS

X-RAY [KUB]– KIDNEYS, URETERS,
BLADDER
SIMPLE FILM
 NO PREP
 DETERMINES SIZE, SHAPE, LOCATION AND
SYMMETRY

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NURSING IMPLICATIONS
 NON-INVASIVE
EXAMINATION OF
THE BLADDER AND KIDNEYS
 CT
SCAN –
 DETAILED IMAGES OF
STRUCTURES. TUMORS AND
OBSTRUCTIONS MAY BE VISIBLE
 PREP: BOWEL CLEANSING
 DETERMINE PATIENT ALLERGY TO
IODINE (INJECTED DURING PROCEDURE)
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NURSING IMPLICATIONS

NON -INVASIVE EXAMINATION OF
KIDNEYS AND BLADDER

IVP: INTRAVENOUS PYELOGRAM
VIEWS COLLECTING DUCTS, RENAL PELVIS,
URETERS, BLADDER AND URETHRA
 PREP: BOWEL CLEANSING



ASSESS PATIENT’S ALLERGY TO IODINE AND SHELLFISH
POST TEST ENCOURAGE FLUIDS TO FLUSH DYE
FROM SYSTEM

MONITOR FOR DELAYED ALLERGIC REACTION
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NURSING IMPLICATIONS

NON-INVASIVE EXAMINATION OF THE
KIDNEYS AND BLADDER

ULTRASOUND OF THE BLADDER
 IDENTIFY GROSS RENAL STRUCTURES
AND STRUCTURAL ABNORMALITIES
 NO PREP REQUIRED
 SIMPLE ULTRASOUND (BLADDER SCAN)
CAN BE DONE ON THE NURSING UNIT
TO EVALUATE RETAINED URINE (POST
VOIDED RESIDUAL – PVR)
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DIAGNOSTIC EXAMINATIONS
OF THE URINARY SYSTEM

INVASIVE EXAMINATION OF THE
KIDNEYS AND BLADDER

CYSTOSCOPY

DIRECT VISUALIZATION OF THE BLADDER
AND URETHRA

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POST PROCEDURE
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SPECIMEN COLLECTION
DONE USING CONSCIOUS SEDATION

VITAL SIGNS
INTAKE AND OUTPUT
DESCRIBE URINE
ENCOURAGE FLUIDS
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CATHETER INSERTION
MALE AND FEMALE

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REQUIRES A PROVIDER ORDER
EXPLAIN PROCEDURE TO PATIENT
ASSEMBLE EQUIPMENT
ASSESS PATIENT
Do you need help? Probably!
 Can [female] pt maintain lithotomy position?
 Can patient hold still? Keep hands away?


This is A STERILE PROCEDURE!!
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Evidence Based Practice

Avoid inserting a catheter


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Why is it being done? Document reason, date, time
Use aseptic technique for insertion
Ongoing care
Closed system, bag position
 Personal hygiene [soap and water] BID
 Catheter care per protocol


Remove promptly [RN or MD decision]
(Dailly, 20110
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Evidence Based Practice

Daily documentation protocols –




date inserted/reason/still needed?
Documentation of peri-care and catheter care
Drainage system [closed system, bag above floor & below
bladder]
Computerized reminders, stop dates, RN initiative aid
in timely removal of indwelling catheters
(Dailly, S. Prevention of Indwelling Catheter-Associated Urinary Tract Infections. Nursing Older People, 23:2; March 2011)
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Reasons for Foley Insertion

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Increased comfort for terminal patients
Management of incontinence

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Protection of skin
Measurement of urine in critical patients
Pre- or Post-op bladder drainage
Urinary retention
Urodynamic or Radiologic testing
Bladder treatments [ chemo]
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SUPRAPUBIC CATHETERS

SURGICAL PLACEMENT OF A
CATHETER THROUGH THE
ABDOMINAL WALL ABOVE THE
SYMPHYSIS PUBIS INTO THE BLADDER
APPROPRIATE FOR USE IN PARAPLEGIC,
QUADRIPLEGIC AND COMATOSE
PATIENTS
 SLIGHTLY LESS CHANCE FOR INFECTION
OVER THE LONG TERM

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CONDOM CATHETERS



FOR MALE PATIENTS ONLY
ALTERNATIVE TO CATHETERIZATION
LATEX OR SILICONE SHEATH THAT
FITS ON PENIS
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CATHETER
IRRIGATION/INSTILLATION

IRRIGATION
INTERMITTENT
 CONTINUOUS
 PRN


INSTILLATION

MEDICATION
ANTISEPTIC
 ANTIBIOTIC

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CLOSED CATHETER
IRRIGATION

CATHETER HAS THREE LUMENS


IRRIGANT, DRAINAGE, BALLOON
CALCULATING URINE OUTPUT
ADD TOTAL AMOUNT OF IRRIGANT
INSTILLED
 ADD THE TOTAL AMOUNT OF URINE PLUS
IRRIGANT MEASURED OUT
 THE DIFFERENCE IS URINE OUTPUT

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NURSING PROCESS AND
ALTERATIONS IN URINARY FUNCTION

ASSESSMENT

SUBJECTIVE INFORMATION
DIFFICULTY URINATING?
 PAINFUL URINATION?
 INCONTINENCE?
 FREQUENCY?
 URGENCY?
 LEAKING?


Usual patterns, changes, fluid intake
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NURSING PROCESS AND
ALTERATIONS IN URINARY FUNCTION

ASSESSMENT

OBJECTIVE DATA

ASSESS URINE

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COLOR
ODOR
AMOUNT
REVIEW LABORATORY FINDINGS
PHYSICAL ASSESSMENT
ABDOMINAL DISTENTION
 RETENTION [bladder scan] after voiding

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Nursing Process: Diagnosis

Nursing Diagnoses for Urinary Elimination
Altered/ Impaired Urinary elimination r/t urethral
obstruction/indwelling urinary catheter/ altered
sensation…..
 Total/functional/stress/urge Urinary Incontinence
 Risk for infection R/T indwelling urinary catheter
 Fluid/Electrolyte imbalance R/T decreased renal
function
 Impaired skin/tissue integrity R/t irritation &
moisture [urine on skin] 2° to incontinence

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Nursing Process: Diagnosis



Disturbed Body Image r/t urinary diversion
[suprapubic catheter] OR urine leakage
Risk for Injury [fall] r/t wet floor 2° to
incontinence, confusion
Knowledge deficit r/t catheterization
techniques/ fluid intake need/toilet retraining

Remember, focus on client issues not medical diagnosis
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Nursing Process: Goals


Long term goal: Normal Urinary
Elimination
Pt will achieve:
Normal Voiding with complete bladder
emptying [per bladder scan] within 14
days
 Urine output > 30ml/hr, 300ml/void
 Continence of urine tonight
 Increased fluid intake of 1500ml/ day
 Pain-free urination 6X/day

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Nursing Process: Goals

Goals focus on pt/ client:
Intake [fluids, acidification]
 Output [urine]
 Comfort
 Safety
 Infection/risk
 Demonstration of Knowledge/ techniques



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E.g. Kegel, straight cath, ‘normals’
Skin Integrity [especially for incontinent
pts]
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NURSING INTERVENTIONS
TO PROMOTE NORMAL URINATION

INTAKE AND OUTPUT

INTAKE: ALL LIQUID TAKEN IN
PO FLUIDS
 IV FLUIDS


OUTPUT

MEASURE ALL FLUIDS ELIMINATED FROM
BODY




URINE
WOUND DRAINAGE
NG DRAINAGE
DIARRHEA
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NURSING INTERVENTIONS
TO PROMOTE NORMAL URINATION






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

Perineal Care/ Hygiene
Catheter Care
Toileting training
Environmental – Obstacles, access, privacy
Position, privacy, running water
Fluid intake
Acidification of urine
Medications
Straight Cath Technique
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Nursing Process: Evaluation






Measure & Document Output
Assess characteristics of Urine, S/SX of UTI,
Hydration status
Urinary Patterns
Pt/ Family statements
Goal met? Partially met? Not Met? AEB?
Revision or continuation of plan?
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Ongoing Research & Practice



Alternatives to indwelling catheters
Decreasing risks of UTI in pts with Foleys
Treatment protocols for +bacteria in urine
Catheter is likely colonized
 Antibiotics only treat free-floating bacteria, not
biofilm on Foley [+ increase risk of C Diff]
 Assess for symptoms of infection [e.g. fever]
 Change Foley and get fresh specimen to confirm
UTI

[Dailly, 2011]
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END
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