王克芳 wangkf@sdu 0531-88382201 山东大学护理学院

1. 第十一章 排泄 Elimination 王克芳 wangkf@sdu.edu.cn 0531-88382201 山东大学护理学院

2. 能正确陈述尿液、粪便观察的主要内容。 能举例说明影响排尿、排便的因素。 能识别常见的排尿异常与排便异常。 能正确解释导致排尿异常和排便异常的原因。 能针对患者的情况制定改善排尿异常与排便异常的护理措施。 能运用所学知识对患者进行排泄护理健康教育。 能规范完成导尿术与灌肠术的操作。 学习目标

3. Anatomy and Physiology Assessment of Urination Nursing Interventions for Urination Nursing Skills for Urination Section 1 Urinary Elimination

4. Anatomy and Physiology • Urine formation • Hormone production • Kidneys • Diameter:1.25 cm • Length: 20 to 30 cm Ureters Bladder • --Hollow, distensible, muscular organ • Organ of excretion • Reservoir of urine Urethra F：4-5cm，短、直、粗 M:18-20cm 3个狭窄 2个弯曲 • Internal sphincter • External sphincter :voluntary

5. Act of Urination

6. Act of Urination volume400-500ml Pelvic nerve micturition center （S2-S4） bladder stretch sensor spinal cord Pelvic nerve parasympathetic impulses micturition center （brain stem, cerebral cortex） detrusor muscle contract internal urethral sphincter relaxing Desire to void external urethral sphincter relaxing Voding--Emptying bladder

7. Section 1 Urinary Elimination 你经历过或听别人说过所谓的排尿方面的问题吗 案例

8. Ignore the urge External sphincter remains contracted Eventually, bladder capacity is maximum Pressure on sphincter makes voluntary control impossible Neurogenic bladder Spinal cord injury above sacral region Loss of voluntary control of urination: incontinence Sacral region injury Retention Blockage Retention Problems

9. Normal Patterns Altered Urinary Elimination Factors Affecting Urination Assessment of Urination

10. Times Amounts Color Clarity Specific gravity pH Odor Normal Patterns

11. Times: 3-5 at daytime 0-1 at night Amounts: 200-400 ml/time 1000-2000 ml/24hr Normal Patterns

12. Color Pale, straw to deep yellow – normal More concentrated in morning Dark red Bleeding from kidneys or ureters Bright red Bleeding from bladder or urethra Dark amber High levels bilirubin Liver dysfunction Normal Patterns

13. Clarity Transparent when fresh – normal Foamy--Kidney disease Thick and cloudy--Bacteria Specific gravity 1.015-1.025 Higher Concentrated urine: Dehydration, reduced renal blood flow, increased ADH Lower Dilute urine: Overhydration, early renal disease, inadequate ADH Normal Patterns

14. pH 4.5-7.5average: 6.0 Indicates acid base balance Odor Slightly aromatic (fresh) – normal Ammonia --Stagnant Sweet or fruity Diabetes Starvation Normal Patterns

15. Oliguria（少尿）, Anuria（无尿）, Polyuria（多尿） Frequency（尿频）, Urgency（尿急）, Dysuria（尿痛） Urinary Incontinence（尿失禁） Retention of urine（尿潴留） Altered Urinary Elimination

16. <400ml/24 hr Dehydration Renal failure Increased ADH >2500ml/24 hr Excess fluid intake Diabetes Diuretics Oliguria Anuria Polyuria • <100ml/24 hr • Severe shock • Acute renal failure

17. 膀胱刺激征 (Bladder Irritation Syndrome) • Frequency--Urination at more frequent intervals • Increased fluid intake • Bladder inflammation • Increased pressure on bladder • Urgent micturition --A sudden strong desire to urinate • Full bladder • Urinary tract inflection • Psychological stress • Dysuria--Difficult or painful urination • Bladder inflammation • Trauma • Inflammation of urethra

18. Definition: Holding urine in the bladder and can’t excrete voluntary 尿液大量存留于膀胱内而不能自行排出 Causes Urethral obstruction Trauma Altered motor and sensory innervation of bladder Medication side effects anxiety Urinary Retention(尿潴留)

19. Urinary Incontinence • Definition • International Continence Society (ICS) ： • Condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable • 客观存在的不自主性尿液排出，并对社会活动和个人卫生造成不良影响。

20. Categories of Incontinence • 压力性尿失禁（Stress Incontinence） • 充溢性尿失禁（Overflow Incontinence） • 急迫性尿失禁（Urge Incontinence） • 功能性尿失禁（Functional Incontinence）

21. Occurs with increase in abdominal pressure coughing, straining, sneezing, lifting heavy objects, etc. The most common type in women, mid-aged, elderly A result of weakened pelvic muscles A malfunction of the urethral sphincter Childbirth Lack of estrogen Pelvic surgery Obesity Stress Incontinence

22. Abrupt desire to void which cannot be suppressed Common in women and the elderly Causes: The majority of cases are idiopathic Infection, tumor, stones, urethritis, stroke, Parkinson’s Disease, dementia Urge Incontinence 厕所 --那么近 --却那么远

23. The uncontrollable leakage of small amount of urine from a overfilled and enlarged bladder Bladder outlet obstruction BPH, fecal impaction Non-contractile bladder diabetes, spinal injury, medications Overflow Incontinence

24. mental or physical disabilities to control urinating, the urinary system itself is normal. Conditions that can lead to functional incontinence : Parkinson's disease dementia Mental confusion may prevent both recognition of the need to void and locating a bathroom. Severe depression Functional Incontinence

25. Fluid Intake Age Health Status and treatment Emotional Status Others Factors Affecting Urination

26. Fluid Homeostasis Input = output Caffeine promotes urine formation Alcohol inhibits ADH Fever causes diaphoresis Fluid Intake

27. Age • Young • Control of urination begins between 2 to 3 years of age • Nighttime : cannot control till age 4 or 5 • Elderly • Mobility problems • Chronic neurological problems • Changes in kidney and bladder function

28. Health Status Diseases • Peripheral nerve lesions • Loss of bladder tone • Reduced sensation • Difficulty in control • Physical disability • Difficult to reach/use toilet

29. Stress of surgery Triggers General Adaptation Syndrome Increased ADH Elevated aldosterone Anesthetic analgesics Slows glomerular filtration rate Impairs sensory and motor impulses Lower abdominal and pelvic area surgery Edema and inflammation Surgery Health Status

30. Prevent reabsorption Diuretics Urinary retention Anticholinergics Antihistamines Antihypertensives Color change Toxic to kidneys Medications Health Status

31. Anxiety Stress Urgency Frequency Muscle tension Difficult to relax abdominal and perineal muscles Emotional Status

32. Social cultural norms Privacy environment Facilities Habits Proper positioning Climate Other factors

33. Nursing interventions for urination • Urinary Retention • Urinary Incontinence

34. Privacy environment Normal position Sensory stimuli Muscle relaxing Health education habits：time voiding Medications 灌肠/排便诱导排尿 Catheterization Interventions for Urinary Retention patient • Squatting for female • Standing for male • Running water • Hand in water • Warm the bedpan 耻骨上膀胱区热敷或针灸

35. Maintain skin integrity, promote comfort External drain the urine Restore normal micturition Interventions for Urinary incontinence patient Offer fluid: 2000-3000 ml/day Bladder Retraining: Take to bathroom q1-2H Pelvic floor muscle training, PFMT(Kegel's ) 收缩与放松盆底肌群 开始各持续2秒，重复15次，Tid 每周增加1秒收缩与放松时间，至10秒 维持10秒，重复10次，Qd Catheterization Psychological support

36. Plastic, rubber or silica gel tube through urethra into bladder Continuous flow of urine Assess hourly urine output Medication therapy Catheterization Nursing skills for urination

37. Catheterization Types • Intermittent Catheterization • Insert long enough to drain bladder • Repeat PRN • Indwelling Catheterization • Stays in place • Change periodically

38. Intermittent urinary retention--Relieve bladder distention Obtain urinary specimen Assess residual Long term management of spinal cord injury Indwelling Obstruction Surgery （pelvic area、Urinary system） Measure I&O in critically ill Urinary incontinenceand Severe retention Terminally ill with trouble moving Indications

39. Care---Maintain flow and prevent infection Sterile Maintain closed system Hang lower than bladder Clean with soap and water at least Qd Area and tube After each BM (bowel movement) Maintain fluid intake Removal of indwelling catheter Promote normal bladder function Prevent trauma Need order--Explain, empty, remove Care and Removal

40. Nursing skills for urination Nursing Implications to Urine Tests • All specimens must be labeled with name, date and time of collection • Transported in time • If unable, refrigerate • Wear gloves

41. Random Midstream Timed Common Urine Tests • Clean, not sterile • Don’t contaminate with stool • Specific gravity; pH; • Glucose • Catheterized • Culture and sensitivity • Test renal function and urine composition • 12 or 24 hours • Creatinine clearance, • protein

42. Urinary Elimination Kidney Ureter Bladder Urethra Oliguria Anuria Polyuria Frequency urination Urge urination Words • Dysuria • Stress Incontinence • Overflow Incontinence • Urge Incontinence • Functional Incontinence • Retention of urine • Intermittent Catheterization • Indwelling Catheterization • Bladder Irrigation

43. 了解： 与排尿有关的解剖与生理。 熟悉： 影响排尿的因素。 掌握： 掌握对排尿活动的评估及护理。 教学目标