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What does the process of urination depend on for effective functioning?
- Upper urinary tract
- Lower urinary tract
- Cardiovascular system
- Nervous system
What does the upper urinary tract include?
What does the lower urinary tract include?
- pelvic floor
How does the nervous system play a role in the effective functioning of the urinary sytem?
A pt needs sensation that bladder is full.
What are some developmental factors influencing urinary elimination?
2 yr. old child getting toilet trained vs. 5 yr. old child
What are some psychosocial factors influencing urinary elimination?
- Fear of sound of toilet flushing
- Bring male child to woman's bathrm, what age is appropriate?
- Bathroom not clean enough affects ability to go
- Need quiet or total privacy to go
What are some fluid balance factors influencing urinary elimination?
- Not enough intake.
- Or not enough output.
What are some medication factors influencing urinary elimination?
- Some meds could increase output.
- Some meds can interfere with elimination.
How does muscle tone affect urinary elimination?
If muscle tone is poor, the sensation to void becomes poor as well.
What are some pathologic conditions that can influence urinary elimination?
- Kidney stones
- Swelling can interfere
What are some surgical and diagnostic procedures that can influence urinary elimination?
- spinal anesthesia
What is an example of a disease that can affect urinary elimination?
Prostatic Hyperplasia, which is an enlarged prostate.
Normal voiding is every...
Frequency will vary based on...
- fluid consumption
- bladder capacity
- availability of toilet
- magnitude of insensible fluid loss
- sweat excretion
- temp of room
At what age does voluntary control of our urinary system start?
During our growth and development what do we require to express our needs?
- verbal communication skills: "potty, pee, tinkle, piddle"
- comfortability with language, some pts don't know "void" meaning
In growth and development of a person, what do we need to recognize?
- Recognition of sensation of bladder filling
- Hold urine 1-2hrs
List the different psychosocial factors influencing urinary elimination?
- European countries have communal toilets
- Men stand, women sit
- Rural areas may not have indoor plumbing
- May need distraction to relax, running water
- Anxiety can cause urgency or prevent bladder emptying > catherize, which then causes fear
What are all the fluid balance factors?
- Caffeine, Alcohol
What does diuresis cause?
increased urine excretion
What effect does caffeine and alcohol have on fluid balance?
Decreases ADH which causes increased fluid loss
How does dehydration affect fluid balance?
The body attempts to retain fluid so output decreases, and concentration increases.
What are the benefits of an accurate I&O and daily wt? Which one is better?
- I&O will show a few days trend.
- Daily wt shows day to day and r/t to fluid changes.
Daily wt is the BEST overall indicator.
When the kidneys produce an abnormally large amount of urine, what is this called?
When there is low urine output < 500cc/day, therefore 20.8cc/hr (30cc/hr is normal), what is this called?
This is a lack of urine production, what is this called?
What are the different classes of meds that affect the urinary system?
- Anticholinergics & decongestants
These meds increase urine output by preventing reabsorption of water and electrolytes. What kind of meds are these?
These meds cause urinary retention. They also dry secretions, but retain urine.What are these meds known as?
Anticholinergics and decongestants
These meds can slow glomerular infiltration. They cause changes in the color of the urine from orange to green or blue, to black or brown. What are these meds called?
- Anesthesia (esp. epidural)
- Opioid analgesics
How do weak abdominal and perineal muscles affect a pt?
They can impair bladder contraction and/or urethral control.
What happens to the muscles of women after childbirth, menopause, and elderly ppl?
What else can decrease muscle tone?
Long term indwelling catheter use
What are all the pathologic conditions that can affect urinary elimination?
- Kidney disease/kidney stones
- Protein or blood cells
- Heart or circulatory disorders
- Blocked flow
- Spinal anesthetics
What are the two types of UTI?
What organ does cystitis affect?
What organ does pyelonephritis affect?
What are s/s of cystitis?
- suprapubic pain
- confusion in elderly
- darker blood
What are the s/s of pyelonephritis?
- flank pain
- pain @costovertebral angle
- bright red blood
What kind of teaching and prevention could a nurse do for someone with a UTI?
- Drink more fluids
- Showers are better than baths
- Perineal cleansing "front to back"
- Voiding after intercourse
- Anti-Microbial Therapy
- No scented toilet paper
- No perfumes, etc to perineal area
- Empty bladder regularly
How would a UTI be medically diagnosed?
- Dipstick for Leukocyte Esterase and Nitrates
- UA/ C&S
- High risk for older adults
What would Tx be for UTI?
- Increase fluid intake
What are all the factors concerning surgical procedures that can affect urinary system?
- Stress > decreased ADH secretion
- Lower abdomen and perineal surgery causes edema > interferes with voiding
In older adults what do we watch out for?
- Illness or surgery
- Decreased renal function
- Decreased bladder function
This decrease in blood flow impairs renal function. What is this called?
What happens to our nephrons as we age?
Why does illness or surgery affect urinary system?
It takes longer to return to normal functioning
This increases the risk for med toxicity of meds that are excreted via kidneys. What is this called?
Decreased renal function
This increases the risk of nocturnal frequency. What is it?
Decreased bladder capacity
What does menopause do for women's urinary system?
- The urethra is affected by decreased levels of estrogen which cause atrophic changes.
- The changes increase risk of infection and urinary incontinence.
How do we promote and maintain normal voiding pattern in our pts?
- Increase intake (no juice if diabetic)
- Offer BRP - less risk for incontinence
- Being ambulatory increases circulation
- Foley tubing is below the bladder
- Washing hands
- Perineal care
What would we ask to fill out history of pt?
- Voiding pattern
- Urinary appearance
- Recent changes
- Past/current problems with urination
What would we do for the physical assessment?
- Percussion of kidneys
- Inspect urethral meatus for swelling, discharge, and inflammation
- Inspect skin for color, texture, turgor, edema, and excoriation
- Bladder scan
What does BUN stand for? What does it do?
Blood Urea Nitrogen- the excretion of urea, indicates glomerular function and hydration status
What does creatinine levels tell us?
Creatinine is a byproduct of muscle metabolism. The level indicates kidneys ability to excrete.
A BUN level >20 means
- serious, glomerular is not working well
- dehydration, excessive protein intake
- impaired renal function
How can we get a false result of BUN level?
r/t hydration status, didn't drink enough water
A low BUN means...
- liver damage
What is GFR? What does this indicate?
Glomerular Filtration Rate– better indication of kidneys than BUN/creatinine
What is the normal GFR level?
0-15 GFR is...
15-60 GFR is...
How do we find the GFR, what tests do we need? What is this test called?
- 24 hr urine
- Serum creatinine levels
What produces creatinine?
Muscles produce relatively constant quantities.
When there is renal impairment what happens to serum creatinine and urinary clearance?
- Serum creatinine goes up
- Urinary clearance goes down
Someone with unilateral kidney disease, what happens to creatinine clearance?
A decrease is not expected if other kidney is healthy
What race makes a difference when it comes to GFR?
How do we obtain urine specimen for culture and sensitivity?
- "Clean Catch" specimen
- Cleanse perineal area with soap and water
- Midstream urine into sterile container– females: spread labia, males: penis doesn't touch container
What characteristics do we look for in a U/A?
If a U/A has been sitting for a long time then what is the odor like?
Diabetics U/A has a _______odor.
A urine specimen that has a malodorous odor means...
If a U/A test pos for protein, what does this mean?
If a U/A tests pos for glucose, what does this mean?
If a U/A tests pos for ketones?
What is normal specific gravity?
What is the specific gravity of water?
If specific gravity of water is low what does this mean?
If specific gravity of urine is high, what does this mean?
Urine is concentrated
Even if Nitrites and Leukocyte esterase test pos we still need_________ to confirm UTI.
Culture of bacteria
The longer the U/A sits...
the higher the pH, altering results
"Bed wetting", involuntary control past age of normal development
If one voids >2x/night means
This is the desire to go
Secondary eneuresis is...
normal urinary elimination then bed wetting started.
What are the characteristics of a neurogenic bladder?
- Impaired neuro function
- Unable to perceive bladder fullness
- Unable to control the urinary spincters
- Bladder becomes flaccid / distended / spastic with freq involuntary urination
Emptying of the bladder is impaired
What are these all characteristic of?
How do we assess urinary retention?
How do we assess for bladder distention?
- Bladder scan
What do we palpate for bladder distention?
Bladder is firm, and may be to one side of midline
What kind of percussion do we listen for bladder distention?
Dull sound represents fluid (bowel sounds have an air sound)
How do we decrease catherization?
What risks do we take when we do urinary catherization?
- Indwelling vs. intermittent catheter
- Duration of use
What kind of trauma can result from catherizing?
Alteration in skin integrity
The longer a catheter is in the urinary system, then...
the higher the risk for infection
What nursing interventions will we take for our pt with an indwelling catheter?
- Encourage po
- Ensure foley bag is below bladder
- Assure patency
- Avoid tension on tubing
- Prevent contamination
- Observe flow Q2-3H
- Patient teaching– involve pt about reason for increasing fluids
When we collect a specimen from the foley catheter what do we do?
- Wash hands
- Scrub the hub, 15-20sec with alcohol, air dry
- Clamp/kink tubing (5-10min)
- Syringe into port
- Transfer to sterile container
- Patient label
In order to d/c an indwelling catheter, what do we do?
- Doctor's Order
- Duration of use, how long used?
How long is normal for a pt to void after having a foley catheter?
- 6-8 hrs
- >8 hrs could mean urinary retention
What is a suprapubic catheter?
Inserted surgically thru abdominal wall directly into the bladder
This is a surgical re-routing of urine from the kidneys to a site other than the bladder, what is this called? What are the 2 categories?
- Incontinent– urostomy
- Continent– neobladder with intestine + pt empties
What are some Nursing Dx?
- Impaired Urinary Elimination
- Dysfunctional in Urine Elimination
What are the interventions for maintaining normal elimination?
- Promoting fluid intake
- Assisting with toileting
- Maintaining normal voiding habits (establish baseline)
- Preventing UTI's
What kinds of nursing management can we do for urinary incontinence?
- Individual bladder program– offer BRP Q2H / pelvic muscle exercises
- Meticulous skin care
- Containment of urine (condom catheter– leave 1" to promote urine flow)
What are the benefits of kegel exercises?
- Strengthen pelvic floor muscles
- Reduce or eliminate episodes of stress incontinence (coughing, laughing, sneezing, lifting)
How do we do a kegel exercises?
- Sit or lie in a comfortable position
- Contract and relax pelvic muscles 3-5 sec
- 10x/3x a day, increasing to 10 sec hold
How do we identify our pelvic muscles?
- You can stop urine midstream
- Tightening anal sphincter as if to hole a bm
What's the purpose behind the condom catheter?
- Collect urine and control urinary inc
- To permit pt physical activity while controlling urinary incontinence
- Prevent skin irritation as a result of urine inc
After applying a condom catheter what should the nurse do?
Check the penis for adequate circulation 30 min after applying (1" space)
Even in a healthy elder this urinary elimination change can occur....why?
The amt of urine retained after voiding increases because of decrease in muscle tone.