Transcript Urinary System

Chapter 45
Urinary Elimination
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Scientific Knowledge Base:
Organs of Urinary Elimination
Kidneys
Ureters
Remove waste from the
blood to form urine
Transport urine from the
kidneys to the bladder
Bladder
Urethra
Reservoir for urine until the
urge to urinate develops
Urine travels from the
bladder and exits through
the urethral meatus.
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Urinary System
Urinary System Organs
Renal Nephron
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Quick Quiz!
1. A patient with a long-standing history of
diabetes mellitus is voicing concerns about
kidney disease. The patient asks the nurse
where urine is formed in the kidney. The
nurse’s response is the
A. Bladder.
B. Kidney.
C. Nephron.
D. Ureter.
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Case Study
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Mrs. Vallero 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. Vallero’s indwelling urinary catheter was
removed 2 days ago and subsequently was replaced
yesterday at 6 AM 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.
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Additional Kidney Functions
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Production of erythropoietin is essential to
maintaining a normal red blood cell (RBC) volume.
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Production of renin, prostaglandin E2, and
prostacyclin affects blood pressure.
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Erythropoietin stimulates bone marrow to produce RBCs and
prolongs the life of mature RBCs.
Renin starts a chain of events that cause water retention,
thereby increasing blood volume.
Prostaglandin E2 and prostacyclin aid vasodilation.
Kidneys affect calcium and phosphate regulation
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Renin-Angiotensin Mechanism
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Act of Urination
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Brain structures influence bladder function.
Voiding: Bladder contraction + Urethral
sphincter and pelvic floor muscle relaxation
1. Stretching of bladder wall signals the micturition
center in the sacral spinal cord.
2. Impulses from the micturition center in the brain
respond to or ignore this urge, thus making
urination under voluntary control.
3. When a person is ready to void, the external
sphincter relaxes, the micturition reflex stimulates
the detrusor muscle to contract, and the bladder
empties.
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Factors Influencing Urination
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Disease conditions
Medications and medical procedures
Socioeconomic factors (need for privacy)
Psychological factors (anxiety, stress,
privacy)
Fluid balance
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Nocturia, polyuria, oliguria, anuria
 Diuresis
 Fever
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Case Study (cont’d)
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Sandy notes that the urinary catheter was removed at
7 AM this morning, and the patient has no recorded
urine output for the day. Mrs. Vallero verifies that she
has only “dribbled” urine. While making rounds,
Sandy talks with Mrs. Vallero, 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.
Vallero at 3 PM with a return of 600 mL of pale, clear
yellow urine.
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Disease Conditions Affecting
Urination
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Prerenal, renal, postrenal classification
Conditions of the lower urinary tract
Diabetes mellitus and neuromuscular diseases such
as multiple sclerosis
Benign prostatic hyperplasia
Cognitive impairments (e.g., Alzheimer’s)
Diseases that slow or hinder physical activity
Conditions that make it difficult to reach and use toilet
facilities
End-stage renal disease, uremic syndrome
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Indications for Dialysis
Renal failure that can no longer be
controlled by conservative management
Worsening of uremic syndrome
associated with end-stage renal disease
(ESRD)
Severe electrolyte and/or fluid
abnormalities that cannot be controlled
by simpler measures
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Case Study (cont’d)
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As Sandy prepares to assess Mrs. Vallero again, she
remembers that urinary problems are common in
patients who have diabetes and in older adults. Age
alone does not cause incontinence. She recalls that
patients with urinary retention sometimes leak or
“dribble” urine and are then misdiagnosed as
incontinent.
She knows that patients generally void at least every
6 to 8 hours, and that Mrs. Vallero’s recent
catheterization, her decreased mobility, and her
history of diabetes make her more prone to urinary
retention, incontinence of small amounts of urine, and
urinary tract infection (UTI).
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Medical Interventions Affecting
Urination
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Surgical procedures
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Medications
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Restriction of fluid intake lowers urine output.
Stress causes fluid retention.
Some cause urinary retention and/or overflow incontinence.
Some cause urgency and incontinence.
Some change the color of urine.
Diagnostic examinations
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Restriction of fluid intake lowers urine output.
Direct visualization causes localized trauma and edema;
patients may have difficulty voiding.
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Alterations in Urinary Elimination
Urinary retention
Urinary tract infection
An accumulation of urine
due to the inability of the
bladder to empty
Results from catheterization
or procedure
Urinary incontinence
Urinary diversion
Involuntary leakage of urine
Diversion of urine to
external source
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Older Adults
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Provide frequent opportunities to void. Older
adults have a smaller bladder capacity than
younger adults.
Encourage older adults to empty the bladder
completely before and after meals and at
bedtime.
Encourage patients to increase fluid intake to
at least six to eight glasses a day unless
medically contraindicated.
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Quick Quiz!
2. A health care provider may suspect that a
patient is experiencing urinary retention when
the patient has
A. Large amounts of voided cloudy urine.
B. Pain in the suprapubic region.
C. Spasms and difficulty during urination.
D. Small amounts of urine voided 2 to 3 times
per hour.
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Case Study (cont’d)
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Sandy knows that she will need to assess whether
Mrs. Vallero feels the urge to urinate. She determines
that no one has taken Mrs. Vallero to the bathroom
recently. Sandy also needs to find out more about her
patient’s urination patterns at home because Mrs.
Vallero has verbalized anxiety about her present
voiding patterns.
Previous clinical experience has taught Sandy that
palpation of the abdomen over a distended bladder
causes some discomfort, and that the patient often
experiences an urge to urinate. Mrs. Vallero grimaces
when her abdomen is palpated and says she has a
little dolor (pain).
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Types of Urinary Diversions
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Nursing Knowledge Base
Infection control and hygiene
Growth and development
Muscle tone
Psychosocial considerations
Cultural considerations
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Nursing Process: Assessment
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Nursing history
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Patterns of urination
Symptoms of urinary alterations
Factors affecting urination
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Case Study (cont’d)
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Findings:
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Patient is able to palpate bladder, 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 the specific assessment activities
that produced these findings?
What other assessment questions should be
asked?
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Urine Collection in Children
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Specimen collection from infants and children
is often difficult.
Adolescents and school-aged children usually
are able to cooperate.
Preschool children and toddlers have
difficulty voiding on request.
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Quick Quiz!
3. A young girl is having problems urinating
postoperatively. You remember that children
may have trouble voiding
A. In bathrooms other than their own.
B. In a urinal.
C. While lying in bed.
D. In the presence of a person other than their
parents.
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Physical Assessment
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Gather nursing history for the patient’s urination
pattern and symptoms, and factors affecting
urination.
Conduct physical assessment of the patient’s body
systems potentially affected by urinary change.
Assess characteristics of urine.
Assess the patient’s perception of urinary problems
as it affects self-concept and sexuality.
Gather relevant laboratory and diagnostic test data.
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Physical Assessment
Skin and mucosal
membranes
Kidneys
Assess hydration.
Flank pain may occur with
infection or inflammation.
Bladder
Urethral meatus
Distended bladder rises
above symphysis pubis.
Observe for discharge,
inflammation, and lesions.
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Assessment of Urine
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Intake and output
Characteristics of urine
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Color
• Pale-straw to amber color
Clarity
• Transparent unless pathology is present
Odor
• Ammonia in nature
Urine testing
• Specimen collection
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Urine Tests and Diagnostic
Examinations
Urinalysis
Specific gravity
Culture
Noninvasive procedures
Invasive procedures
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Urine Drainage Bag
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Urine Specimen Collection
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Checking Results of a Chemical
Reagent Strip
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Nursing Diagnosis and Planning
• Social isolation
• Pain
(acute, chronic)
• Disturbed body image
• Urinary incontinence
(functional, stress, urge,
overflow)
• Risk for infection • Toileting self-care deficit
• Impaired skin
• Impaired urinary
integrity
elimination
• Constipation
• Urinary retention
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Case Study (cont’d)
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Nursing diagnosis: Urinary retention related
to weakened detrusor muscle and recent
removal of indwelling urinary catheter
Goal: Mrs. Vallero will have normal micturition
within 1 month.
What expected outcomes would you establish
to measure goal achievement?
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Implementation
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Health promotion
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Patient education
Promoting normal micturition
Stimulating micturition reflex
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Maintaining elimination habits
Maintaining adequate fluid intake
Promoting complete bladder emptying
Preventing infection
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Types of Male Urinals
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Case Study (cont’d)
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Interventions for urinary retention care
include:
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Assist with toileting every 2 to 3 hours while
awake.
 Instruct the patient/family to record urinary output
as appropriate.
 Have Mrs. Vallero take a warm bath if unable to
urinate.
 Use Credé’s method with each attempted void.
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Implementation
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Acute care
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Maintaining elimination habits
• Allow time and provide privacy.
Medications
• Parasympathetic stimulation of the detrusor muscle aids
emptying.
• Cholinergic drugs increase bladder contraction and
improve emptying.
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Catheterization
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Catheterization
Catheter insertion
Closed drainage systems
Catheter care
Perineal hygiene
Fluid intake
Catheter irrigations and instillations
Removal of indwelling catheter
Alternative to urethral catheterization
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Types of Urinary Catheters
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Urinary Drainage System and
Infectious Organisms
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Applying a Condom Catheter
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Applying a Condom Catheter (cont’d)
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Applying a Condom Catheter (cont’d)
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External Urinary Device
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Implementation: Restorative Care
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Strengthening pelvic floor muscles
Bladder retraining
Habit training
Self-catheterization
Maintenance of skin integrity
Promotion of comfort
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Evaluation
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Evaluate whether the patient has met
outcomes and goals.
Check how the patient reports progress
made.
Help the patient redefine goals if necessary.
Revise nursing interventions as indicated.
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Case Study (cont’d)
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Sandy talks with Mrs. Vallero the next evening. The
patient’s care plan incorporates scheduled voiding,
oral fluids, and use of Credé’s method of manual
compression during voiding. She palpates
Mrs.Vallero’s bladder and then assists her to the
toilet.
After making sure she is comfortable and leaving the
call light in place, Sandy instructs her to use Credé’s
method of manual compression. She returns to
measure Mrs. Vallero’s urinary output and evaluates
for bladder residual using an ultrasound bladder
scan.
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Case Study (cont’d)
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Ask Mrs. Vallero about her urge to void,
sensation of bladder fullness, and dribbling
episodes.
Have Mrs. Vallero keep a log of her pattern of
elimination, including urine output volumes
with each voiding, during the 1-month period.
Ask Mrs. Vallero if she continues to have
lower abdominal pain.
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Case Study (cont’d)
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Mrs. Vallero is concerned about regaining her
urinary function. Sandy develops the
following outcome for her: At the end of the
teaching session, Mrs. Vallero will be able to
describe approaches to promote normal
urinary elimination habits.
What teaching strategies would you put into
the plan?
What evaluation strategies would you use?
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Safety Guidelines
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Follow principles of surgical and medical asepsis as
indicated when performing catheterizations, handling
urine specimens, or helping patients with their
toileting needs.
Identify patients at risk for latex allergy (i.e., patients
with history of hay fever; asthma; and allergies to
certain foods such as bananas, grapes, apricots, kiwi
fruit, and hazelnuts).
Identify patients with allergies to povidone-iodine
(Betadine). Provide alternatives such as
chlorhexidine.
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