Ch 29 urinary elimination PDF

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Fundamental Concepts and skills for nursing textbook...

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Chapter 29: Promoting Urinary Elimination •

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Which structures are involved in urinary elimination? o Kidney's bean shaped, 2 ½ inch wide, 5 inch long,1 inch thick o Level of L1 on each side of spine o Male urethra 8 inches, female 1 ½ to 2.5 o Kidneys filter blood through nephrons, metabolic waste, and excess water extracted ▪ Assist in acid base balance by retaining or excreting H+ ions and bicarbonate HCO3- ions o Kidneys manufacture 1 – 1.5 L of urine on average 24 hours o Bladder can hold 1000-1800mL of urine o Average urine output is 1000-1500mL/day Factors that interfere with urinary elimination o Total loss of kidneys ability to manufacture urine (kidney failure) may result in anuria (absence of urine) o Dec kidney perfusion = kidney damage o Blockage of ureters: stone, tumor pressure, trauma o Pressure on urethra from enlarged prostate o Childbirth o Infection o Neurologic damage to nerves that control internal and external sphincters or muscular wall of bladder cause alteration in urinary patterns o Prostate surgery What changes in the system occur with aging o Dec in number of functioning nephrons and reduction in rate of renal filtration with aging o Bladder muscle tone decreases, capacity lessens ▪ Causes nocturia (urinating during the night) ▪ Incontinence is not a normal part of aging ▪ Incomplete bladder: residual urine • Becomes stagnant and predisposes person to infection • Lower estrogen levels in women cause result in tissue atrophy in urethra: predisposes person to infection and incontinence Normal urinary elimination o Infants: 5-40 times a day o Preschool: every 2 hours o Adult: 5-10 times a day ▪ Male: 300-500 mL ▪ Female: 250 ▪ Hourly output of urine 30 mL (reflects adequate kidney perfusion) Factors affecting normal urination o Neurologic and muscle development o Alterations in spinal cord integrity o Volume of fluid intake

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o Amount of fluid lost by perspiration, vomiting, diarrhea, and ADH Characteristics of normal urine o Color: shade of yellow, straw colored or amber o Smoky red or dark brown: blood or myoglobin (byproduct of muscle tissue injury) o Very dark amber urine: presence of bilirubin Clarity o Transparent or slightly cloudy ▪ Cloudy urine= bacteria or large amounts of protein Odor o Smells faintly like ammonia o Infection present is foul smell Specific gravity o Thinness or thickness of urine o Measured by urinometer: reads the amount of light the urine absorbs or by a chemical dipstick o Normal range: 1.010 - 1.030 but conditions such as dehydration and fluid excess may extend the range slightly in either direction PH o Acidity or alkalinity of urine measure in units called pH. PH slightly acidic 5.5-7 Alterations in urinary elimination o Normally sterile, but provides a good medium for the growth of infectious organisms if they are introduced into the bladder o Common UTI: cystitis ▪ Caused by irritation of highly concentrated urine, bacteria, injury, or instillation (putting in a solution) of an irritating substance ▪ Escherichia coli bacterium is responsible for cystitis ▪ Frequency, urgency, dysuria, burning, malaise, foul smelling urine, slight temp elevation o Anuria: less than 100 mL of urine excreted in 24 hours ▪ Can be caused by urinary suppression (kidneys not forming urine) ▪ Can be caused by retention of urine (all urine is not expelled from bladder during voiding) o Dysuria (painful or difficult urination) ▪ Occurs when there is inflammation present in bladder or urethra o Incontinence o Nocturia: urinate at night o Oliguria (dec amount of urine output ▪ Falls below 400 mL/24 hr ▪ Sign of kidney failure, blockage of urine o Polyuria (excessive urination) ▪ 1500 mL in 24 hr ▪ Diabetes mellitus (absence of insulin) or diabetes insipidus (decreased production of ADH)

Application of the Nursing Process •

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Assessment o History o Cath o I and o o Last patient voided o Each patient should void at least every 8 hours unless an indwelling catheter is in place o Urine specimen collection ▪ Urine that stands for 15 minutes or more change characteristics and urinalysis will not be accurate o Sterile catheterized specimen ▪ Straight cath o 24-hour specimen ▪ Amount of a specified chemical that is excreted through the urine in a 24-hour period ▪ Some urine thrown out, start over ▪ Empty's bladder just before beginning ▪ Cold o Urinary collection bag ▪ Obtain specimen from infant or toddler ▪ Sufficient urine collected bag removed and urine poured into specimen container o Strained specimen ▪ Suspected of having urinary stone, all urine strained when voided o Urine specimen from an indwelling catheter ▪ Clamp tubing ▪ Aspirate 3 mL by pulling it back ▪ Sterile container Diagnoses o Urinary elimination impaired o Retention o Inco o Body image o Infection o Pain o Injury o Self-care deficit o Risk for impaired skin integrity o Knowledge Planning o Prone to UTI, increase fluids, unless contradicted and reinforce patient education regarding ways to prevent further uti’s Implementation

Assisting patients with urinary elimination Bed pan Fracture pan: can't sit on regular sized bed pan ▪ Smaller surface area ▪ Used for patients with musculoskeletal problems ▪ Flat end with wide rim placed under patient by separating patients' legs and slipping pan under butt Assisting with use of urinal o Place in urinal spread legs Placing / removing bedpan o Ask patient to bend knees and press down with feet while you slip one hand under lower back for assistance o Helpless patient: patient on side, roll patient over Helping a patient urinate o Run water o Deep breath o Male stand by side of bed o Female blow through straw in a glass of water o Measure cups of warm water and pour over perineum o Massage from top of bladder to bottom o Sitz bath Reasons for catheterization o Surgery o Dilating urethral stricture o Splinting urethra following surgery o Measuring amount of residual urine o Monitoring hourly urine output or obtaining exact measurements of total output Types of urinary catheters o Straight cath: relieve retention from patient who is unable to void or obtain a sterile specimen o Foley cath: holds more, for continuous drainage after surgery o Coude cath curved and has rounded or bulbous tip that is easier to insert into male urethra when prostate is enlarged o Alcock cath: continuous bladder irrigation following prostate or bladder surgery, o Depezzer cath: tip shaped like mushroom, used for suprapubic drainage o Malecot cath: large single tube used for nephrostomy tube, placed into pelvis of kidney o Condom cath: condom with a tube attached to distal end ▪ Provide continuous urine drainage for male in noninvasive way Care in indwelling cath o Fluid o Closed drainage system o Measure every 8 hr o Wash hands o Empty bag via spout o o o

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o Drainage tubing o Perineal care twice daily Suprapubic cath: urine drainage following gynecologic and bladder surgery and inserted into wall Intermitted self cath o Used for patients who regular experience inc Bladder irrigation or installation o Wash out residual urine or sediment o Remove clots o Sooth bladder tissue o Lumen o Instill medication into bladder o Continuous irrigation performed after prostate or bladder surgery via three-way indwelling cath where irrigation solution is hooked up to the irrigation port of the catheter o Check bladder for distension o Open sterile irrigation set o Pad under o Clamp drainage tubing distal to cath (clamping directs solution toward bladder and prevents solution from draining into collection bag) o Determine the amount of urine in the drainage bag before beginning irrigation (amount of urine must be subtracted from the total drainage at the end of the procedure to determine if all irrigation solution is returned o Pour 100-200 mL or irrigating solution into sterile container using aseptic tech o Draw 30-40 mL of solution into syringe while maintaining sterility expel air and attach syringe to sterile insertion connecter o Antiseptic swab: scrub port on the drainage tubing for instilling solution o Attach sterile insertion connecter into port and instill solution o Remove insertion connecter from port and cleanse. Place o For irrigation: immediately unclamp tubing and lower cath so that fluid runs into drainage tubing o Bladder installation: leave clamped for ordered amount of time then unclamp it and allow fluid to run into drainage container o Repeat o Empty bag and note characteristics of drainage Types of incontinence o Urge: involuntary loss of urine due to sensation of needing to empty bladder (diabetes, stroke, infection, medical condition) o Stress: sphincter failure associated with inc intra-abdominal pressure as occurs with sneezing, laughing, coughing and aerobic exercise o Mixed: combination of different types of stress and urge o Overactive powerful, immediate urges to urinate frequently and possibly urge incont o Overflow poor contractility of detrusor muscle of bladder and obstruction of urethra may be related to prostate enlargement in male or genital prolapse in female

Functional: cognitive inability to recognize urge to urinate, extreme depression or dementia, inability to reach bathroom because of restraints, side rails, or physical impairment o Transient: temp urinary loss caused by a condition that is likely to resolve (new medication or coughing) Urinary diversion care o When bladder removed or bypassed o One or both ureters implanted into abdominal wall o Opening: urostomy o When changing place tampon o

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