Module 10 -PART 1 - Lecture notes 10 part 1 PDF

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Module 10, WEEK 10 PART 1 URINARY ASSESSMENT

1. Introduction Learning objectives      

Review the anatomy and physiology of the urinary system. Understand the assessment techniques and terms associated with the urinary system. Discuss urinalysis, the meaning of a routine urinalysis and the collection of urine samples. Demonstrate the ability to maintain an accurate fluid balance chart. Identify normal and abnormal characteristics of urinary function. Develop nursing diagnoses, desired outcomes and interventions related to clients with urinary care needs

2. Anatomy and Physiology 3. Assessment techniques Importance of urinary assessment An assessment of the renal system includes all aspects of urinary elimination       

Urinary pattern, incontinence, frequency, urgency, dysuria Hydration status including fluid balance, BP and weight Growth and feeding, diet or fluid restrictions Skin condition: temperature, turgor and moisture Urine output (Normal children 2yrs is between 0.5-1ml/kg/hr) Urinalysis (pH, ketones, protein, blood, leukocytes, specific gravity) Review blood chemistry results, urea, creatinine, electrolytes, albumin and haemoglobin.

Physical assessment The physical assessment of the client with a known or suspected renal or urologic disorder includes an assessment of general appearance, a general review of body systems, and specific structure and functions of the renal/urinary systems. The nurse assesses the general appearance of the client and assesses the client's general level of consciousness and level of alertness, noting deficits in concentration, thought processes, or memory. Assessment of the kidneys, ureters, and bladder is performed in conjunction with an abdominal assessment. Auscultation is performed before percussion and palpation because these activities can enhance bowel sounds and obscure abdominal vascular sounds. CONSIDERATIONS PRIOR TO ASSESSMENT

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Preparation of the patient: Explain the procedure to the patient. Gain consent from the patient. Analyse the patient's condition and make sure to choose an appropriate time to perform the assessment. Consider the patient's cultural and gender backgrounds. Positioning of the patient: Position the patient in a supine position for urinary assessment. Make sure the patient is comfortable in that position. Preparation of the environment: Analyse and adjust the environment to allow for placement of the equipment. Clear any clutter in the environment. Make sure the room is at the right temperature as the patient is going to be exposed. Privacy: Provide privacy to the patient by pulling curtains across or closing the door. Also be mindful that the patient is not exposed more than they should be. Patient information should be kept private and confidentiality should be maintained. Equipment: All equipment should be gathered and assembled prior to performing the assessment. Equipment required for urinary assessment include stethoscope, observation machine and various charts.

INSPECTION The nurse inspects the abdomen and the flank regions with the client in both the supine and the sitting position. The client is observed for asymmetry (e.g., swelling) or discoloration (e.g., bruising or redness) in the flank region, especially in the area of the costovertebral angle (CVA). The CVA is located between the lower portion of the twelfth rib and the vertebral column. Also a patient with sever renal failure will also have a yellow tint to there skin and especially the sclera. AUSCULTATION The nurse listens for a bruit over each renal artery on the mid-clavicular line. A bruit is an audible swishing sound produced when the volume of blood or the diameter of the blood vessel changes. A bruit is usually associated with blood flow through a narrowed vessel, as in renal artery stenosis. PALPATION Renal palpation identifies masses and areas of tenderness in or around the kidney. The abdomen is lightly palpated in all quadrants. The nurse asks about areas of tenderness or discomfort and examines nontender areas first. The outline of the bladder may be seen as high as the umbilicus in clients with severe bladder distention. Special training and practice under the guidance of a qualified practitioner are necessary; therefore appropriate education is essential before attempting the procedure. If tumor or aneurysm is suspected, palpation may harm the client. Because the kidneys are deep, posterior structures, palpation is easier in thin clients who have little abdominal musculature. For palpation of the right kidney, the client assumes a supine position while the nurse places one hand

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under the right flank and the other hand over the abdomen below the lower right part of the rib cage. The lower hand raises the flank, and the upper hand depresses the anterior abdomen as the client takes a deep breath (Figure 69-10). The left kidney is deeper and rarely palpable. A transplanted kidney is readily palpable in either the lower right or left abdominal quadrant. The kidney should feel smooth, firm, and nontender. PERCUSSION A distended bladder sounds dull when percussed. After gently palpating to determine the general outline of the distended bladder, the nurse begins percussion on the skin of the lower abdomen and continues in the direction of the umbilicus until dull sounds are no longer produced.

Terms to become familiar with Urinary retention: is an inability to completely empty the bladder. Urinary incontinence: is the involuntary leakage of urine; in simple terms, it means a person urinates when they do not want to. Urinary frequency: is the need to empty the bladder more than once every two hours. Dysuria: painful or difficult urination. Urinary urgency: the sudden need to empty the bladder. Nocturia: The need to urinate more than twice at night. Haematuria: Blood in the urine.

Bladder scan The bladder scanner is a non invasive method of assessing bladder volume using ultrasonography. Bladder scanning helps to measure the post void residual volume (amount of urine left in the bladder after urination). It is simple and causes no discomfort to the client.The bladder scan provides assessment data, biofeedback in bladder retraining, assessment for catheter malfunction, and aids in assessing urinary retention and renal failure, and the effectiveness of anticholinergic medication on voiding. The bladder scan should be a standard investigation for at-risk groups presenting with bladder problems.

4. Fluid balance charts Fluid balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic processes to function correctly. To make a competent assessment of fluid balance, nurses need to understand the fluid compartments within the body and how fluid moves between these

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compartments. Two-thirds of total body fluid is intracellular, and the remaining third is extracellular fluid, which is divided into plasma and interstitial fluid. Normal fluid balance can be interrupted by illness.

Measurement of fluid balance chart Water intake is obtained from fluid and food in the diet, and is mostly lost through urine output. It is also lost through the skin as sweat, through the respiratory tract, vomiting and faecal matter. Monitoring a patient’s fluid balance to prevent dehydration or overhydration is a relatively simple task, but fluid balance recording is notorious for being inadequately or inaccurately completed. Some of the reasons why fluid balance charts were not completed appropriately were staff shortages, lack of training, and lack of time. When documenting fluid balance charts, it is important to know how many millilitres of fluid are in an intravenous medication, a glass of water or a cup of tea, how frequently the fluid balance chart data should be recorded – such as hourly or two hourly – should be clearly documented. It is not acceptable practice to use shorthand. For patients using a bedpan or urinal to urinate, the urine should be poured into a measuring jar (if unclear to read) and the urine output should be recorded. Usually the fluid balance charts are added up at the end of the day. Some of the instances where a fluid balance chart is commenced would be for a patient on intravenous therapy, indwelling catheter, dehydration, nasogastric feeds, postoperative, wound drains, fluid restriction and renal failure.

Documentation and communication According to the Nursing and Midwifery Council, record keeping is an integral part of nursing care, not something to be “fitted in” where circumstances allow. It is the responsibility of the nurse caring for a patient to ensure observations and fluid balance are recorded in a timely manner, with any abnormal findings documented and reported to the nurse in charge. To maintain an accurate fluid balance chart the intake (oral fluids/ intravenous fluids/ nasogastric feeds) and output (urine, vomitus, drain output) should be closely monitored and documented correctly. Accurate Fluid Balance Chart Time

Oral input

IVI input Cumulative Urine Bowels Vomit Cumulative input output output output output

08.00 Water Normal 250ml 150ml saline 0.9% 100ml

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550ml

550ml

09.00

100ml

350ml

10.00 Coffee 100ml 150ml

600ml

250ml 800ml

11.00 Water IVI 900ml 300ml tissued 12.00

Venflon sited

13.00

100ml

150ml 350ml

950ml 1,300

1,000ml

14.00 Tea 150ml

1,150ml

15.00

100ml

1,250ml

16.00 Water 75ml

100ml

1,425ml

17.00

100ml

1,525ml

18.00 Tea 100ml 150ml

1,775ml

100ml 1,400ml

200ml

1,600ml 100

1,700ml

Inaccurate Fluid Balance Chart Time

Oral input IVI input

08.00

Tea

100ml??

H20

50ml

Cumulative input

Urine output

Bowels output

PU+++

Diarrhoea

Vomit output

?

09.00 10.00 11.00

Tissued

12.00

+++ Bed wet

13.00

Soiled bed linen

Venflon sited

14.00 15.00

Tea

200ml??

BO+++

Pump not working 16.00 17.00

Juice

5. Specimen collection Specimen collection techniques across the lifespan

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Cumulative output

Instruction for your patients to collect midstream urine (MSU) specimen: GIRLS AND WOMEN

Girls and women need to wash the area between the vagina "lips" (labia).   

Instruct your patient to sit on the toilet with their legs spread apart. Ask patient to use two fingers to spread open the labia. Instruct the patient to use a wipe to clean the inner folds of the labia and to wipe from the front to the back. A second wipe is used to clean over the opening where urine comes out (urethra), just above the opening of the vagina.

To collect the urine sample: Spread open the labia, urinate a small amount into the toilet bowl, then stop the flow of urine. Hold the urine cup a few inches from the urethra and urinate until the cup is about half full and the patient can finish urinating into the toilet bowl.

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BOYS AND MEN

Instruct patient to clean the head of the penis with a sterile wipe. If patient is not circumcised, you will need to pull back (retract) the foreskin first. Instruct patient to urinate a small amount into the toilet bowl, and then stop the flow of urine. Then collect a sample of urine into the clean or sterile cup, until it is half full and the patient can finish urinating into the toilet bowl. INFANTS

A special bag is used to collect urine in babies. It will be a plastic bag with a sticky strip on one end, made to fit over your baby's genital area. Wash the area well with soap and water, and dry. Open and place the bag on your infant.  

For boys, the entire penis can be placed in the bag. For girls, place the bag over the labia.

Check the baby often and remove the bag after the urine collects in it. Active infants may displace the bag, so you may need to make more than one attempt. Drain the urine into the container. After collecting the sample, screw the lid tightly on the cup. Do not touch the inside of the cup or the lid and sent it to the labortary for investigation.

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Different types of specimen samples Suprapubic catheter (SPC) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into the patient's bladder through a small hole in their belly. The urine sample can be obtained by aspirating the supra pubic catheter. Any growth from SPC urine usually indicates infection (but note, possible contamination by skin commensals or faecal flora may produce a mixed growth).

Indwelling Catheter (IDC) Specimens A catheter is a tube put into the bladder through the urethra to drain urine. The indications of catheter insertion include: Urinary incontinence (leaking urine or being unable to control urination), urinary retention (being unable to empty the bladder when needed to),surgery on the prostate or genitals and other medical conditions such as multiple sclerosis, spinal cord injury, or dementia.

Clean Catch Urine A clean catch is a method of collecting a urine sample to be tested. The clean-catch urine method is used to prevent germs from the penis or vagina from getting into a urine sample.

Midstream urine (MSU) Can be obtained from patients who can void on request. Wash genitalia with water and dry. The first few mls to be voided are not collected, then a specimen is obtained.

Full ward test (dipstick) Urine Full ward test (FWT) can detect urinary protein, blood, nitrites (produced by bacterial reduction of urinary nitrate), and leukocyte esterase (an enzyme present in white blood cells). FWT is a screening test only. If a UTI is suspected, a specimen should be sent for microscopy and culture particularly for children under 3 years of age.

In-out catheter A catheter is inserted to the bladder to obtain an urine sample and then the catheter is taken out straight after. This method is used for patients who are incontinent or are cognitively impaired and cannot follow instructions.

6. Urinalysis Urine analysis adds to the knowledge of a persons health status. Urinalysis as a ward routine is undertaken during admission and as indicated by the person's condition. A fresh specimen of urine is used. The collection receptacle (urinal/ bedpan/ witches hat) should be clean to prevent any changes in test results due to contamination. Urine analysis can also be referred to as Full Ward Tests (FWT). 8

Testing the urine      

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Explain the procedure to the patient and ensure privacy is provided. Instruct the patient to void into sterile container or receptacle. Gather the urine sample, test strip bottle and test strip. Full ward tests are usually performed in the pan room of a clinical setting. Always wear gloves whilst performing urinalysis. It can be ideal to wear eye protective gear to avoid the risk of any contamination. Immerse the dipstick completely in the specimen of fresh urine. Withdraw immediately, drawing or gently tapping edge along rim of container to remove excess. Alternatively you can use a small sterile syringe to draw up the urine sample and then (with care) direct a gentle flow across the dipstick. Ensure all test pads are covered and that you hold the stick over a container to catch the off-flow. This is useful if you are taking your urine specimen form a jar that you want to send to pathology. Placing a ward urinalysis stick directly into the specimen may contaminate it. Allow up to 2 minutes for the results to be displayed. Many nurses simply dip, pause, read; potentially abnormal results.

Characteristics of urine Urine is the fluid containing water and waste products that is secreted by the kidneys, stored in the bladder, and discharged by way of the urethra. The normal range of urine output is approximately 30mls per hour. Report an urinary output of less than 30mls per hour or more than 2000-2500mls per 24 hours. Characteristics  

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Colour - Pale straw to amber: the first urine in the morning is darker . Altered by diet, medical dyes, and disease. Clarity - Transparent and clear. Only test fresh urine. Cloudy or foaming means high protein. Thick and cloudy means bacterial infection.

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Odour - Characteristic odour. Concentrated means stronger odour. Stagnant means ammonia e.g: incontinent. Sweet means diabetes mellitus or starvation.

Normal Urine Values Component

Normal

Values

PH

4.6-8 (Adults and children) 5-7 (Newborns)

Colour

Pale yellow to amber

Clarity

Clear

Specific gravity

1.010-1.020

Protein

None to trace

Glucose

None

Ketones

None

Blood

0- 2 RBCs

Documentation and communication The documentation of all output is required in some patients. Knowledge of the individual documentation requirements is necessary as, some patients may only need a daily record of their urination in the progress note, whereas other patients need an hourly record of their urine output. Urinalysis is documented on the vital signs sheet. Specific gravity, colour, clarity and any abnormal findings are to be recorded. Establish a fluid balance chart if necessary and note on the care plan to monitor intake and output.

7. Incontinence Urinary incontinence is the uncontrolled loss of urine that constitutes a social or hygienic problem. Urinary incontinence is often referred to as accidents or leakage events.

Types There are two primary types of urinary incontinence, namely: acute and chronic.  

Acute urinary incontinence- is a transient and reversible loss or urine, caused by an acute illness or after an injury. Chronic urinary incontinence- is a persistent condition caused by underlying physical problems or changes. They are divided into: stress urinary incontinence, urge incontinence, functional and overflow incontinence.

1. Stress incontinence: is the uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction. The frequency of stress incontinence in women increases with age. Some of

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the causes include multiple vaginal deliveries, oestrogen deficiency, obesity, bladder suspensions and prostate conditions. 2. Urge incontinence: is the loss of urine caused by a premature or hyperactive contractor of the detrusor. The cause can be neurological or idiopathic. 3. Functional incontinence: is the loss of urine caused by altered mobility, dexterity, access to the toilet or changes in cognition. These conditions are worsened in an unfamiliar environment, such as hospitals. 4. Overflow incontinence: is the uncontrolled loss of urine that exists when the sphincter mechanism has been bypassed. Some of the causes are prostatic enlargements, urethral tumour, faecal impaction, immobility, spinal conditions.

Risk factors The risk factors most commonly linked with urinary incontinence include:       

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pregnancy (both pre- and post-natal women) younger women who have had children menopause obesity urinary tract infections constipation specific types of surgery such as pros...