Chapter 46 Notes: Urinary Elimination PDF

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Personal notes on chapter 46 in Potter/Perry Fundamentals of Nursing:)...

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Chapter 46: Urinary Elimination

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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

Kidneys Contribute to: -Elimination -Electrolyte Balance -Blood Pressure -Bone maturation (red blood cells) -The kidneys lie on either side of the vertebral column, left is higher than the right due to anatomical position of the liver Nephrons: The functional unit of the kidneys, that remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance within each nephron is a cluster of capillaries called the Glomerulus filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes -Large proteins and blood cells DO NOT normally filter through the glomerulus -When there is blood (Hematuria) or proteins (Proteinuria) filtered through the glomerulus, injury is suspected -99% of glomerular filtrate is reabsorbed into plasma by proximal convoluted tubule, Loop of Henle, and distal tubule -1% of filtrate is actually excreted -Reabsorption process is what keeps fluid and electrolyte balances maintained -Normal range of Urine is 1-2 L/day -Kidneys produce Erythropoietin stimulates red blood cell production and maturation of bone marrow -Pts. with chronic kidney disease do not produce sufficient quantities of this hormone and develop Anemia -Kidneys play a role in Blood Pressure control via the renin-angiotensin system -Renal Ischemia= release of Renin from juxtaglomerular cells -Renin enzyme that converts Angiotensinogen (in liver) into Angiotensin1converted into Angiotensin2 in the lungs causes vasoconstriction and release of Aldosterone in Adrenal Cortex -Aldosterone retention of water and increases blood volume Blood Pressure Increase -Kidneys also produce prostaglandin E2 and prostacyclinmaintain renal blood flow through vasodilation  Renal blood flow increase -Kidneys also affect calcium and phosphate regulation by producing substance that converts vitamin D into its active form damage= decrease in vitamin D production Ureters -Attach to each kidney pelvis and carry urinary waste to the bladder (sterile) -Peristaltic waves cause the urine to enter into the bladder sporadically rather than at constant flow -Contractions of the bladder compress lower parts of the ureters to prevent urine from back flowing into the kidneys

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-Obstruction of urine flow (kidney stone)back flow of urine (urinary reflux) into ureters and pelvis of the kidney which causes distention (hydroureter/hydronephrosis) and can cause permanent damage to sensitive kidney structures and function as well as infection Bladder -Hollow distensible and muscular organ that holds urine -When emptylies in the pelvic cavity and behind the symphysis pubis -In males, the bladder rests against the rectum and in women it rests against the anterior wall of uterus and vagina -2 parts: Trigone (base) and Detrusor (body) -Low pressure in bladder prevents backflow into the ureters and kidneys -Pregnant women fetus pushes against the bladder= reduced capacity, causing the feeling of being full Urethra -Urine travels through the bladder though the urethra and out of the body through the urethral meatus -Urethra passes through a thick layer of muscles called the Pelvic Floor musclesstabilize urethra and contribute to urinary continence -External urethral sphincter (striated muscles)contributes to voluntary control over the flow of urine -Female urethra= 3-4cm/1-1.5 inches long** Risk for UTI-close access to bacteria contaminated perineal area -Male urethra= 18-20cm/7-8 inches long Act of Urination Urination= Micturition= Voiding all describe process of emptying the bladder -Interaction among bladder, urinary sphincter, and central nervous system -Cerebral Cortex, Thalamus, Hypothalamus, and brainstem -Two micturition centers in spinal cord: One that coordinates contraction of bladder and one that inhibits the contraction of the bladder -While bladder fills contractions are inhibited by SNS stimulation from the thoracic micturition center urinary sphincters constrict and bladder relaxes -When bladder fills to approx. 400-600 mL= sense of urgency CNS then sends message to micturition centers, stopping SNS stimulation and starting PSNS stimulation from the sacral micturition centerurinary sphincter relaxes and the bladder contracts Factors Influencing Urination -Physiological Factors -Psychological conditions -Diagnostic or treatment-induced Factors Common Urinary Elimination Problems -Involve the inability to store urine or fully empty urine from the bladder -Can result from: -Infection -Irritable/Overactive bladder -Obstruction of urine flow -Impaired bladder contractility -Issues that impair innervation to the bladdersensory or motor dysfunction

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Urinary Retention -Inability to partially or completely empty the bladder -Stretches bladder causing feeling of: -Pressure -Discomfort/Pain -Restlessness -Sometimes Diaphoresis -Tenderness over pubis symphysis -No urine output over several hours -Frequency -Urgency -Small-volume voiding -Incontinence of small volumes of urine -Chronic Urinary Retention= slow and gradual onset in which pts. may experience: -Decreasing in void volumes -Staining to void -Frequency -Urgency -Incontinence -Sensations of incomplete emptying -Postvoid residual (PVR) is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization -Overflow incontinence or Incontinence associated with chronic retention of urine: Incontinence caused by urinary retention pressure in the bladder exceeds the ability of the sphincter to prevent the passage of urine, and the pt will “dribble” urine Urinary Tract Infections -One of the most common health care-acquired infections, with almost all caused by instrumentation of the urinary tractcausative pathogen found in colon= E.Coli -Risks for UTI include: -Indwelling catheter -Any instrument of urinary tract -Urinary retention -Urinary and fecal incontinence -Poor Hygiene -Upper UTI= Kidney -Lower UTI= Bladder and Urethra -S/S of Infection (fever, body aches, ect.) -Bacteriuria bacteria in the urine, does not always mean UTI -Asymptomatic Bacteriuria: When there is bacteria in the urine but there are no signs of infection not considered an infection BUT should be treated with antibiotics

-Symptomatic infection could lead to serious upper UTI (pyelonephritis) and life-threatening bloodstream infection (bacteremia or urosepsis) and should be treated also with antibioticsS/S: Fever, Chills, Diaphoresis, and Flank Pain -Lower UTI (bladder) symptoms: -Burning/pain with urination (Dysuria) -Irritation of the bladder (Cystitis) -Urgency -Frequency -Incontinence -Suprapubic tenderness -Foul-smelling cloudy urine -Delirium in Older Adults -Hematuria -Catheter-associated UTI’s (CAUTI’s): associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs -Urine samples need to be done carefully to prevent contamination -For critically ill patients: Urine sampling must be done either routinely once a week or at the beginning of a new episode of sepsis -CAUTI is usually deemed present if at least 10^3 colony-forming units (CFU)/mL of 1 or 2 microorganisms are identified by urine culture -Risk Factor: Urinary Indwelling Catheter insertion and how long it is installed

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Urinary Incontinence -Defined as “Complaint of any involuntary loss of urine” -Affects 70% of elderly nursing home pts. -Urgency UI: involuntary leakage associated with urgency -Stress UI: involuntary loss of urine associated with effort or exertion on sneezing or coughing -Mixed UI: mixture of both (stress and urgency) -Overactive bladder: 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: urine leakage caused by an overfull bladder -Functional UI-caused by factors that prohibit or interfere with a pts. access to the toilet or other acceptable receptacle for urine -Significant in older adults who experience problems with mobility or the dexterity to manage their clothing and toileting behaviors -Multifactorial Incontinence: 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 Urinary Diversions -Patients who have had the bladder removed (Cystectomy) because of 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 -UD are constructed from section of intestine to create a storage reservoir or conduit for urine -Temporary or Permanent/Continent or Incontinent - Continent Urinary Reservoir: created from a distal part of the ileum and proximal part of the colon. Ureters are embedded into the reservoir. Situated under the abdominal wall and has a narrow ileal segment brought out through the abdominal wall to form a small stoma. Ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Pts. must be willing and able to catheterize the pouch 4-6 times a day for the rest of their lives. -Orthotopic Neobladder: Uses an ileal pouch to replace the bladder. Pouch is in same place that previous bladder was in, allowing the pt to void through the urethra using a Valsalva technique -Ureterostomy: Or Ileal conduit is a permanent incontinent urinary diversion created by transplanting the ureters into a closed-off part of the intestinal ileum and bringing the other end out onto the abdominal wall forming a stoma -Pt. has no control or sensation over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch -Nephrostomy: 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

**Infection Control and Hygiene** -Urinary Tract is sterile -Follow principles of medical asepsis when carrying out procedures involving the urinary tract or external genitalia -Perineal Hygiene is an essential component of care when there is an alteration in the usual pattern of urinary eliminationRequires medical asepsis, including proper hand hygiene -Catheterization requires sterile aseptic technique

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**Growth and Development** -A patient's ability to control micturition changes during the life span -Neurological systemdeveloped at 2-3 years of agebefore then, child cannot associate sensation of filling and urge with urination -Toilet training becomes successful when: Child can recognize the feelings of urge, can hold urine for 1-2 hours, and is able to communicate his or her needs -Continence starts during daytime hours -Nocturnal Enuresis: Children who wet the bed at night without waking up from sleep -Infants and young children cannot effectively concentrate urine -Their urine appears light yellow or clear -In relation to their small body size, infants and children excrete large volumes of urine. A 6-month old infant who weighs 13-18Ibs. excretes 400-500mL of urine daily. -Pregnancy changes the urinary tractHormonal changes and the pressure of the growing fetus on the bladder cause increased urine production and shrinking bladder capacity -Frequency is common **Implications for Practice with Older adults (Box-46-2)** • Older adults with cognitive impairment may need to be reminded to void more frequently to improve continence. • Evaluate all possible causes of new-onset incontinence, which should include taking note of any new medications that might impact cognition, alertness, mobility, or voiding. • Older adults newly started on an anti-muscarinic medication should be assessed carefully for mental status changes. This class of medications has the potential to cause cognitive impairment in older adults • Older adults with impaired mobility and incontinence should have interventions put in place to maximize self-care and continence (e.g., toileting program, mobility aids, help with hygiene). • Teach older women with stress incontinence about pelvic muscle exercises. There is no age limit on their effectiveness. • The sensation of thirst decreases with aging. Adequate hydration promotes bladder health. Older adults may need to be reminded to drink adequate amounts of water • To decrease nocturia, instruct patients to restrict fluid intake for the 2 hours before bedtime. • Older men with voiding pattern changes (e.g., urgency, frequency, slow stream, decreased output, dribbling) should be assessed for urinary retention because of age-related prostate enlargement.

Psychosocial Implications -Elimination problems effects on self-concept, culture, and sexuality -Incontinence can be devastating to self-image and self-esteem -Can be embarrassing and seen as being treated like a child -May threaten pts. self-determination -Influences body imagethreat to maintaining sexual relationship with partner

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***Nursing Process*** -----Assessment ------Through Pts. eyes -Sensitivity to patient misconceptions will allow you to quickly identify areas for patient education. Always ask what he or she expects from care. For example, does the patient expect that the UTI will be resolved? Does the patient expect the colostomy to be only temporary? -Self-Care Ability -It is very important to thoroughly assess patients' ability to perform necessary behaviors associated with voiding. -Cultural Considerations: -Be aware of cultural and gender differences related to the very private act of voiding and how they affect nursing assessment and care. -Health Literacy: -Assess a patient's understanding of his or her urinary tract problem. -Assess the patient's health literacy level before engaging in education Nursing History: -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

Pattern of urination -Ask the pt. about daily voiding patterns (frequency, times of day, volume at each voiding, history of recent changes) -Frequency varies and depends on: -Fluid Intake -Medications like diuretics -Intake of bladder irritants such as caffeine or other caffeinated beverages -Common times for urination are on awakening, after meals, and before bedtime -Most people void an average of 5 or more times a day -Ask if pt. wakes up from an urge to void It is normal to wake up at night because of factor other than voiding (noise, nighttime treatments) and then have urge to void after Symptoms of Urinary Alternations -Ask pt. about the presence of symptoms related to urination **Common Symptoms of Urinary Alterations**(Box 46-2) Urgency: An immediate and strong desire to void that is not easily deferred Causes: -Inflammation or irritation of the bladder -Full bladder -Urinary tract infection -Overactive bladder Dysuria: Pain or discomfort associated with voiding Causes: -UTI -Inflammation of Prostate -Urethritis -Trauma to lower urinary tract -Urinary tract tumor Frequency: Voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours. Causes: -Bladder outlet obstruction (prostate enlargement, pelvic organ prolapse -UTI -High volumes of fluid intake -Bladder irritants (caffeine) -Increased pressure on the bladder (pregnancy)

Chapter 46: Urinary Elimination Hesitancy: Delay in start of urinary stream when voiding Causes: -Anxiety (voiding in public restrooms) -Bladder outlet obstruction (Prostate enlargement, Pelvic organ prolapse

Polyuria: Voiding excessive amounts of urine Causes: -High volumes of fluid intake -Diuretic therapy -Uncontrolled diabetes mellitus -Diabetes Insipidus Oliguria: Diminished urinary output relation to fluid intake Causes: -Fluid and electrolyte imbalance (Dehydration) -Kidney dysfunction and failure -Increased ADH -Urinary tract obstruction Nocturia: Awakened from sleep bc of urge to void Causes: -Excess intake of fluids before bedtime (alcohol/coffee) -UTI -Overactive bladder -Meds (diuretic @ night) -Cardiovascular disease (hypertension) -Bladder outlet obstruction (prostate enlargement) Dribbling: Leakage of small amounts of urine despite voluntary control of micturition Causes: -Bladder outlet obstruction (P.E) -Incomplete bladder emptying -Stress incontinence Hematuria: Presence of blood in urine Gross Hematuria: Blood easily seen in urine Microscopic Hematuria: Not visualized but measured on urinalysis Causes: -Tumors (kidney, bladder) -Urinary tract calculi -Infection (Glomerular Nephritis, Cystitis) -Trauma to the Urinary tract Retention: Acute Retention: Suddenly unable to void when bladder is adequately full or overfull Chronic Retention: Bladder does not empty completely during voiding, and urine is retained in the bladder Causes: -Bladder outlet obstruction (PE, Urethral Obstruction) -Absent or weak bladder contractility (Neurological dysfunction such as caused by diabetes, MS, lower spinal cord injury) -Side effects of certain medications (anesthesia, anticholinergics, antispasmotics, antidepressants)

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Physical Assessment -Assessment of kidneys, bladder, external genitalia, urethral meatus, and perineal skin Kidneys -Inflammation/infection= tendernessFlank painassess by gently percussing the costovertebral angle (formed by the spine and 12th rib) -Auscultation is sometimes performed to detect the presence of a renal artery bruit (sound resulting from turbulent blood flow through a narrowed artery), but this skill is usually performed by an advanced practice nurse. Bladder -Rests below the pubis symphysis -When distended with urine, will rise above the symphysis pubis and along midline of the abdomen -Very full, extends as far as the umbilicus -On inspection, may observe a swelling or convex curvature of the lower abdomen. -On gentle palpation of the lower abdomen, a full bladder may be felt as a smooth and rounded mass. -Full bladder palpatedpts. report a sensation of urinary urge tenderness or even pain. -If an overfull bladder is suspected, further assessment with an ultrasound device or a bladder scanner is recommended if available External Genitalia and Urethral Meatus -Inspect for drainage/inflammation -Dorsal Recumbent (female) -Observe labia majora for swelling, redness, ect. -Retract labia folds with gloved hand (should be pink and moist) -Urethral meatus will appear irregular or slit like opening below the clitoris and above the vaginal orifice -In postmenopausal women, may be dryer and less pink than that of a young women In male, tightening of foreskin not allowing it to be retracted (Phimosis)= risk for inflammation and infection -Observe penis for any swelling/irritation/redness -Following inspection, be sure to return the foreskin back to unretracted position retracted foreskin can cause dangerous swelling (Paraphimosis) -All pts. with indwelling catheter should have the urinary meatus assessed for catheter-related damage and for the presence of inflammation/discharge -Pulling/traction on catheter can damage urinary meatus -Nurse should inspect the perineal skin exposed to moisture DAILY or more -If pt. complains of burning or itching painObserve for Erythema Assessment of Urine Intake and Output -Evaluates bladder emptying, renal function, and fluid ...