Chapter 45: Urinary Elimination

1. Chapter 45: Urinary Elimination Bonnie M. Wivell, MS, RN, CNS

3. Anatomy • Kidneys remove wastes from the blood to form urine; play a key role in fluid and electrolyte balance • Ureters transport urine from the kidneys to the bladder • The bladder holds urine until the urge to urinate develops • Urine leaves the body through the urethra • Nephron is working unit of kidney; forms urine; contains glomerulus surrounded by Bowman’s capsule • Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal tubule, collecting duct

4. Kidney

5. Filtration • Filtration of H2O, glucose, amino acids, urea, creatinine, and major electrolytes into Bowman’s capsule • Large proteins and blood cells do not normally filter through the glomerulus • Proteinuria = the presences of large proteins in the urine; a sign of glomerular injury • Glomerulus filters approximately 125 mL of filtrate per minute

6. The Kidneys • Normal adult urine output is 1500 to 1600 mL/day • An output of < 30 mL/hr indicates possible renal alteration • Kidneys produce several substances vital to production of RBC, BP, and bone mineralization • Produces erythropoietin which stimulates RBC production and maturation and prolongs the life of the mature RBCs • Patients with chronic alterations in kidney function cannot produce sufficient quantities of this hormone therefore they are prone to anemia

7. The Kidneys Cont’d. • Renal hormones affect BP regulation in several ways • Renin and angiotensin I and II cause vasoconstriction • Aldosterone released resulting in water retention • Prostaglandin – maintains renal blood flow via vasodilation • Affect calcium and phosphate regulation by producing a substance that converts vit D into its active form • Renal bone disease results from demineralization of the bone cause by impaired calcium absorption

8. Act of Urination “Micturition” Brain structures that influence bladder emptying Cerebral cortex, Thalamus, Hypothalamus, Brain Stem Normal voiding involves contraction of the bladder muscles and coordinated relaxation of the urethral sphincter and pelvic floor muscles

9. Act of Urination Cont’d. Factors influencing urination Amount of urine in the bladder Adult normally holds 600mL Child 150 – 200mL Increasing urine volume stimulates the micturition center in the sacral spinal cord Normally voiding is a voluntary process

10. Factors Influencing Urination Disease Conditions Prerenal: decreased blood flow to and through the kidneys Renal: disease conditions of the renal tissue Postrenal: obstruction in the lower urinary tract that prevents urine flow from the kidneys

11. Diseases That Influence Urination Diabetes Multiple Sclerosis BPH – Benign Prostatic Hyperplasia Cognitive Disorders Alzheimer’s Disease End-Stage Renal Disease Requires dialysis

12. Other Factors That Influence Urination Socio-cultural Factors Privacy Psychological Factors Anxiety Fluid balance Surgical procedures Medications Diagnostic examination

13. Terminology to Know NOCTURIA POLYURIA OLIGURIA DYSURIA ANURIA DIURESIS CYSTITIS HEMATURIA PYLONEPHRITIS INCONTINENCE NOCTURNAL ENURESIS

14. 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 micturition reflex Possible Causes Urethral obstruction Surgical trauma Child birth Alterations in sensory innervation Anxiety Side effects of medications

15. Alterations in Urinary Elimination Urinary tract infections (UTIs) Most common healthcare associated infection Catheterization Surgical Manipulation 75% – 95% Caused by E-Coli Any condition resulting in urinary retention (Kinked, obstructed or clamped catheter) increases the risk of bladder infection

16. Alterations in Urinary Elimination Urinary Incontinence Involuntary urination Causes Aging 50% of all LTC residents suffer from incontinence Complications Skin breakdown

17. Alterations in Urinary Elimination Urinary Diversion Divert ureters to abdominal wall stoma Causes Cancer of the bladder Trauma Radiation Chronic cystitis Nephrostomy – drainage via tube placed directly into the renal pelvis

18. Ileal Conduit

19. Nephrostomy

20. Normal vs Abnormal Urine NORMAL URINE VALUES APPEARANCE: Clear COLOR: Amber yellow ODOR: Slight ammonia pH: 4.6 – 8.0 PROTEIN: 0 – 8mg/dl SPECIFIC GRAVITY: 1.005 – 1.030 LEUKOCYTES: Neg NITRITES: Neg KETONES: Neg CRYSTALS: Neg GLUCOSE: Neg RBC: Neg WBC: Neg

21. Normal vs Abnormal Urine Abnormal Findings Increased pH Respiratory or metabolic alkalosis Gastric suctioning Vomiting UTI Decreased pH Metabolic acidosis Diabetes Diarrhea Respiratory acidosis

22. Normal vs Abnormal Urine Increased protein DM CHF Pre-eclampsia Glomerulonephritis Polycystic disease Decreased protein Lupus Heavy-metal poisoning Bladder tumor

23. Normal vs Abnormal Urine Increased Specific Gravity Dehydration Glycosuria, proteinuria Fever Vomiting Diarrhea Decreased Specific Gravity Over-hydration Renal failure Hypothermia Pyelonephritis

24. Normal vs Abnormal Urine Increased RBCs Glomerulonephritis Acute tubular necrosis Cystitis Traumatic catheterization Increased WBCs Bacterial infection in the urinary tract Glomerulonephritis Acute pyelonephritis Lupus

25. 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

26. Psychosocial Considerations Gender differences Males stand to urinate Females sit to urinate How many people lie down to urinate??

27. Nursing Process and Alterations in Urinary Function Assessment Subjective Information DIFFICULTY URINATING? PAINFUL URINATION? INCONTINENCE? FREQUENCY? URGENCY? LEAKING?

28. Nursing Process and Alterations in Urinary Function Assessment Objective data Assess Urine: color, odor, amount Review lab data See Box 45-3 (page 1137) for assessment questions Physical assessment Abdominal distention

29. Common Urinary Alterations URGENCY FREQUENCY HESITANCY RETENTION DRIBBLING INCONTINENCE RESIDUAL URINE

30. Diagnostic Examinations of the Urinary System OBTAINING A URINE SPECIMEN RANDOM CLEAN CATCH (MIDSTREAM) STERILE TIMED COLLECTION

31. Diagnostic Examinations of the Urinary System TESTING THE URINE CHEMICAL REAGENT STRIP (DIP STICK) BEDSIDE URINALYSIS pH GLUCOSE BLOOD KETONES PROTEIN

32. Diagnostic Examinations of the Urinary System Testing the urine Sterile specimen Straight cath Aspiration from indwelling catheter Same procedure from urinary diversion Timed specimen to be sent to lab EXAMPLE: 24-HrUrine for UUN (Urine Urea Nitrogen) Special container/Preservative MUST SAVE ALL URINE OR START OVER Ice

33. Nursing ImplicationsDiagnostic Examinations of the Urinary System Clean catch or midstream Assemble equipment and instruct pt. on technique to obtain specimen Straight Cath (in and out cath) Assemble equipment Explain procedure to pt. Insert catheter using sterile technique Send specimen to lab in sterile container

34. Nursing ImplicationsDiagnostic Examinations of the Urinary System Obtaining sterile specimen from existing urinary catheter Catheter must be clamped for about 30 mins prior to aspiration Using a syringe and large bore needle, access the collection port on the catheter tubing and withdraw 5-10 mL of urine to send to lab

35. Nursing ImplicationsDiagnostic Examinations of the Urinary System Non-Invasive examination of the bladder and kidneys X-RAY: KUB = kidneys, ureters, bladder Simple film, no prep needed Determines size, shape, location and symmetry CT Scan Detailed images of structures. Tumors and obstructions may be visible Prep: NPO, varies Determine patient allergy to iodine (injected during procedure)

36. Nursing ImplicationsDiagnostic Examinations of the Urinary System IVP: Intravenous Pyelogram Views collecting ducts, renal pelvis, ureters, bladder and urethra Prep: Bowel cleansing Assess pt’s allergy to iodine and/or shellfish Post-test encourage fluids to flush dye from system Monitor for delayed allergic reaction

37. Nursing ImplicationsDiagnostic Examinations of the Urinary System Ultrasound of the bladder Identifies gross renal structures and structural abnormalities No prep required Simple US (bladder scan) can be done on the nursing unit to evaluate retained urine (post-void residual – PVR)

38. Nursing ImplicationsDiagnostic Examinations of the Urinary System Invasive Examination of the kidneys and bladder Cystoscopy Direct visualization of the bladder and urethra Specimen collection Done using conscious sedation Post-Procedure Vital signs I&O Describe urine Encourage fluids

39. Nursing Interventions that Promote Normal Urination Intake and Output INTAKE: monitoring and measuring all liquid taken in Oral fluids IV fluids OUTPUT: measure all fluids eliminated from the body Urine Wound drainage NG drainage Diarrhea

40. Catheter Insertion Male and Female Requires a provider order Explain procedure to patient Assemble equipment Assess patient Do you need help? Is the female patient able to maintain lithotomy position? Is your female patient obese?

43. Suprapubic Catheters Surgical placement of a catheter through the abdominal wall above the symphysis pubis into the bladder Appropriate for use in paraplegic, quadraplegic and comatose patients Slightly less chance for infection over the long term

45. Condom Catheters For male patients only Alternative to catheterization Latex or silicone sheath that fits on penis

46. Catheter Irrigation/Instillation Irrigation Intermittent Continuous (CBI) PRN Instillation Medication Antiseptic Antibiotic Chemotherapy

47. Open Catheter Irrigation Clean gloves Sterile procedure Instill normal saline into bladder using a 50 mL catheter tip syringe Catheter, syringe, and irrigant must be sterile

48. Closed Catheter Irrigation • Catheter has 3 lumens • Irrigant, Drainage, Balloon • Calculating urine output • Add total amount of irrigant instilled • Add the total amount of urine plus irrigant drained out • The difference is urine output

50. Nursing Diagnosis Functional urinary incontinence Reflex Urinary incontinence Stress Urinary incontinence Total Urinary incontinence Urge Urinary incontinence Overflow Urinary incontinence Urinary Retention Risk for infection Risk for impaired skin integrity