Ch. 46 Urinary Elimination copy PDF

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Notes on Urinary Elimination...

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• Urinary elimination is a basic human function. This function can be compromised by a wide variety of illnesses and conditions. • Nurses are key members of the health care team when treating patients with urinary problems. It is your role to assess urinary tract function and support bladder emptying. • During acute illness a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised. Some patients require long-term indwelling catheters, urethral or suprapubic, when the bladder fails to effectively empty. • Nurses in all health care settings play an important role in teaching patients about bladder health and in supporting them to improve or obtain continence.

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• Urinary elimination is the last step in the removal and elimination of excess water and byproducts of body metabolism. Adequate elimination depends on the coordinated function of the kidneys, ureters, bladder, and urethra. The kidneys filter waste products of metabolism from the blood. The ureters transport urine from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes and urine leaves the body through the urethra. • The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver. • Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance. The normal range of urine production is 1 to 2 L/day. Erythropoietin, produced by the kidneys, stimulates red blood cell (RBC) production and maturation in bone marrow. The kidneys play a major role in blood pressure control via the renin-angiotensin system, release of aldosterone and prostacyclin. The kidneys also affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form.

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• A ureter is attached to each kidney pelvis and carries urinary wastes to the bladder. • The urinary bladder is a hollow, distensible, muscular organ that holds urine. The bladder has two portions, a fixed base called the trigone and a distensible body called the detrusor. The bladder expands as it fills with urine. • Urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence. The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area. • [Shown is Figure 46-1: Organs of urinary system.]

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• Answer: C

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• Sandy, the nursing student, learns about Mrs. Vallero at the 3 p.m. shift report. • [Ask students: What questions would you have if you were Sandy? Discuss.]

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• Urination, micturition, and voiding are all terms that describe the process of bladder emptying. Micturition is a complex interaction between the bladder, urinary sphincter, and central nervous system. • Several areas in the brain are involved in bladder control; cerebral cortex, thalamus, hypothalamus and brainstem. There are two micturition centers in the spinal cord; one that coordinates inhibition of bladder contraction and the other that coordinates bladder contractility. • As the bladder fills and stretches, bladder contractions are inhibited by sympathetic stimulation from the thoracic micturition center. • When the bladder fills to approximately 400 to 600mL, most people experience a strong sensation of urgency. • When in the appropriate place to void, the central nervous system sends a message to the micturition centers, stopping sympathetic stimulation and starting parasympathetic stimulation from the sacral micturition center. The urinary sphincter relaxes and the bladder contracts. • When the time and place is inappropriate, the brain sends messages to the micturition centers to contract the urinary sphincter and relax the bladder muscle.

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Children cannot voluntarily control voiding until 18 to 24 months. Readiness for toilet training includes the ability to: recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and communicate the sense of urgency.

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Older adults may experience a decrease in bladder capacity, increased bladder irritability and an increased frequency of bladder contractions during bladder filling. In older adults, the ability to hold urine between the initial desire to void and an urgent need to void decreases. Older adults are at increased risk for urinary incontinence due to chronic illnesses and factors that interfere with mobility, cognition, and manual dexterity.

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Cultural and gender norms vary. North Americans expect toilet facilities to be private, whereas some cultures accept communal toilet facilities. Religious or cultural norms may dictate who is acceptable to assist in elimination practices. Social expectations (e.g., school recesses, work breaks) can interfere with timely voiding.

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Anxiety and stress sometimes affect a sense of urgency and increase the frequency of voiding. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. Depression can decrease the desire for urinary continence. The need for privacy and adequate time to void can influence the ability to adequately empty the bladder. If fluids, electrolytes, and solutes are balanced, increased fluid intake increases urine production. Alcohol decreases the release of antidiuretic hormones, thus increasing urine production. Fluids containing caffeine and other bladder irritants can prompt unsolicited bladder contractions resulting in frequency, urgency, and incontinence. Diabetes mellitus, multiple sclerosis, and stoke can alter bladder contractility in addition to the ability to sense bladder filling. Patients will experience either bladder overactivity or deficient bladder emptying. Arthritis, Parkinson’s disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet.

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Spinal cord injury or intervertebral disk disease (above S-1) can cause the loss of urine control due to bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter.

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Prostatic enlargement (e.g., benign prostatic hyperplasia or BPH) can cause obstruction of the bladder outlet causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow requiring temporary use of an indwelling urinary catheter. Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness causing urinary retention (Elsamara and Ellsworth, 2012) Diuretics increase urinary output by preventing reabsorption of water and certain electrolytes. Some drugs change the color of urine (e.g., phenazopyridine - orange, riboflavin - intense yellow). Aniticholinergics (e.g., atropine, OAB agents) may increase the risk for urinary retention by inhibiting bladder contractility (Burchum and Rosenthal , 2016). Hypnotics and sedatives (e.g., analgesics, antianxiety agents) may reduce the ability to recognize and act upon the urge to void. Cystoscopy may cause localized trauma of the urethra resulting in transient (1 to 2 days) dysuria and hematuria.

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Whenever the sterile urinary tract is catheterized, there is a risk for infection. [Review Box 46-1, Factors Influencing Urinary Elimination, with students.]

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• [Ask students: What do you think is happening with Mrs. Vallero? Discuss.]

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• [Ask students: What should Sandy do at the next assessment? Discuss.]

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• The most common urinary elimination problems involve the inability to store urine or to fully empty urine from the bladder. Problems can result from infection, irritable or overactive bladder, obstruction of urine flow, impaired bladder contractility, or issues that impair innervation to the bladder resulting in sensory or motor dysfunction. • Patients may have no urine output over several hours, and in some cases will experience frequency, urgency, small volume voiding or incontinence of small volumes of urine. Postvoid residual (PVR) is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization. Incontinence caused by urinary retention is called overflow incontinence or incontinence associated with chronic retention of urine. The pressure in the bladder exceeds the ability of the sphincter to prevent the passage of urine and the patient will dribble urine. • [Review Table 46-1, Urinary Incontinence, with students.] • Urinary tract infections (UTIs) are usually caused by Escherichia coli. Urinary tract infections are characterized by location; upper urinary tract (kidney) or lower urinary tract (bladder, urethra) and have signs and symptoms of infection. Bacteriuria, or bacteria in the urine, does not always mean that there is an infection. Symptomatic infection of the bladder should be treated with antibiotics and can lead to a serious upper urinary tract infection (pyelonephritis) and life-threatening blood stream infection

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(bacteremia or urosepsis). Symptoms of a lower urinary tract infection (bladder) can include: burning or pain with urination (dysuria), irritation of the bladder (cystitis) characterized by urgency, frequency, incontinence, suprapubic tenderness, and foul-smelling cloudy urine. Catheter-associated UTIs (CAUTIs) are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs. Because a CAUTI is common, costly, and believed to be reasonably preventable, as of October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) chose it as one of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment. Consequently, there has been a shift in reimbursement practices from its traditional focus on early recognition and prompt treatment to one of prevention. • Common forms of UI are urge or urgency UI (involuntary leakage associated with urgency) and stress UI (involuntary loss of urine associated with effort or exertion, on sneezing or coughing. Mixed UI is when stress and urgency type symptoms are both present. Overactive bladder is defined as urinary urgency, often accompanied by increased urinary frequency and nocturia that may or may not be associated with urgency incontinence and is present without obvious bladder pathology or infection. Urinary incontinence associated with chronic retention of urine (formally called Overflow UI) is urine leakage caused by an overfull bladder. Functional UI is caused by factors that prohibit or interfere with a patient’s access to the toilet or other acceptable receptacle for urine. In most cases, there is no bladder pathology. It is a significant problem for older adults who experience problems with mobility or the dexterity to manage their clothing and toileting behaviors. A recently added category of incontinence is identified as Multifactorial incontinence. This describes incontinence that has multiple interacting risk factors, some within the urinary tract and others not, such as multiple chronic illnesses, medications, age-related factors, and environmental factors.

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• Patients who have had the bladder removed (cystectomy) due to cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI, require surgical procedures that divert urine to the outside of the body through an opening in the abdominal wall called a stoma. Urinary diversions are constructed from a section of intestine to create a storage reservoir or conduit for urine. Diversions can be temporary or permanent, continent or incontinent. • There are two types of continent urinary diversions. The first is called a continent urinary reservoir, which is created from a distal portion of the ileum and proximal portion of the colon. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. A ureterostomy or ileal conduit is a permanent incontinent urinary diversion created by transplanting the ureters into a closed-off portion of the intestinal ileum and bringing the other end out onto the abdominal wall forming a stoma. The patient has no sensation or control over the continuous flow of urine through the ileal conduit requiring the effluent (drainage) to be collected in a pouch. • [Shown is Figure 46-2: Types of urinary diversions. A, Content urinary reservoir. B, Urostomy (ileal conduit).]

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• Nephrostomy tubes are small tubes that are tunneled through the skin into the renal pelvis. These tubes are placed to drain the renal pelvis when the ureter is obstructed. Patients do go home with these tubes and need careful teaching about site care and signs of infection. • [Shown is Figure 46-3: Nephrostomy Tubes. (From Lewis SL et al: Medicalsurgical nursing, ed 9, St Louis, 2014, Mosby.)]

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• Answer: D

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• Because heart failure and bed rest have left Mrs. Vallero in a weakened state, Sandy is flexible and creative in designing a plan of care to meet the patient’s elimination needs. • [Ask students: What additional assessment activities should be performed routinely? What would you incorporate into Mrs. Vallero’s plan? Discuss.]

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• Urinary elimination is a basic body function and carries with it a variety of psychological and physiological needs. • The urinary tract is sterile. The use of infection control principles will help to prevent the spread of UTI. Perineal care or examination of the genitalia requires medical asepsis, including proper hand hygiene. Any invasive procedure such as catheterization requires sterile technique. • Growth and development factors will determine the patient’s ability to control the act of urination across the life span. Infants, children, and the elderly experience problems with urination. The young need to learn to recognize the need to urinate. The elderly need to deal with decreased functioning that accompanies aging. Pregnancy causes many changes in the body, including the urinary tract. In early and late pregnancy, urinary frequency is common. • [Review Box 46-2, Focus on Older Adults: Urinary Incontinence, with students.] • The process of micturition is often a private event and requires you to be sensitive to a need for privacy. Incontinence can be devastating to selfimage and self-esteem. When your patient asks for help for such a private and personal activity it can be perceived as embarrassing, being treated like a child, or may threaten the patient’s sense of self-determination.

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• Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate collect necessary information, analyze the data, and make decisions regarding your patient’s care. • During assessment consider all elements that build toward making an appropriate nursing diagnosis. Take into consideration the knowledge you have learned about the urinary system. Integrate the knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the process of urinary elimination and the impact on a patient and family. • Reflect upon previous and personal experiences to help you determine a patient’s elimination needs. Your experience with a UTI helps you to understand the frustration and embarrassment felt by the patient caused by frequency, urgency, and dysuria. Caring for other older adults with functional disabilities helps you to anticipate patient needs related to toileting. • In addition, use critical thinking attitudes such as perseverance to find a plan of care to provide successful management of urinary elimination problems. • Professional standards provide valuable directions for management. You are in a key position to serve as a patient advocate by suggesting

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noninvasive alternatives to catheterization use (e.g., the use of a bladder scanner to evaluate urine volume without invasive instrumentation or implementation of a voiding schedule for the incontinent patient). • Standards and guidelines prepared by nursing specialty organizations as well as those developed by national and international professional organizations are valuable tools to use when critically evaluating patient problems and developing a plan of care. The professional nurse will incorporate such evidenced based guidelines into the plan of care. There are two nursing organizations, the Society for Urological Nurses and Associates (http://www.suna.org) and the Wound, Ostomy, Continence Nurses Society (http://www.wocn.org) that offer many resources related to continence care. Both organizations have specialty certification agencies offering entry level and advanced practice specialty certification. • [Review Box 46-3: Resources for Urology/Continence Nurses, with students.]

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• Apply the nursing process and use a critical thinking approach in the care of patients. The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care. • During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. • Throughout the nursing assessment, it is important for you to consider the patient’s frame of reference related to their illness or urinary problem. Assess the patient’s understanding of the urinary problem and their expectations of treatment. • It is very important to thoroughly assess a patient’s ability to perform necessary behaviors associated with voiding. Investigate their expectations of what the nurse will do and what they can do independently. • Be aware of cultural and gender differences related to the very private act of voiding and how it affects nursing assessment and care. Be sensitive and ask questions in a straightforward manner. Culture will often dictate gender specific roles when it comes to care of elimination issues. It may be inappropriate for a male to touch or even talk about elimination matters with a woman. • [Review Box 46-4, Cultural Aspects of Care: Elimination, with students.]

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• When taking a nursing history you should be careful to assess the patient’s understanding of their urinary tract problem. Limited knowledge of basic anatomy and how the urinary tract functions can contribute to poor understanding and outcomes of treatment. • The nursing history includes a review of the patient’s elimination patterns, symptoms of urinary alterations, and assessment of factors that are affecting the ability to urinate normally. • [Review Box 46-5, Nursing Assessment Questions, with students.] • Ask the patient about daily voiding patterns, including frequency and times of day, normal volume at each voiding, ...