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URINARY ELIMINATION Chapter 45

URINARY ELIMINATION Chapter 45. A&P REVIEW. KIDNEYS REMOVE WASTE FROM THE BLOOD TO FORM URINE URETERS TRANSPORT URINE FROM THE KIDNEYS TO THE BLADDER. A&P REVIEW. BLADDER RESERVOIR FOR URINE UNTIL THE URGE TO URINATE DEVELOPS URETHRA

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URINARY ELIMINATION Chapter 45

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  1. URINARY ELIMINATIONChapter 45 NRS_105/320 Collings

  2. A&P REVIEW KIDNEYS REMOVE WASTE FROM THE BLOOD TO FORM URINE URETERS TRANSPORT URINE FROM THE KIDNEYS TO THE BLADDER NRS_105/320 Collings

  3. A&P REVIEW BLADDER RESERVOIR FOR URINE UNTIL THE URGE TO URINATE DEVELOPS URETHRA URINE TRAVELS FROM THE BLADDER AND EXITS THROUGH THE URETHRAL MEATUS NRS_105/320 Collings

  4. KIDNEY FUNCTION FILTER WASTE FROM THE BLOOD PRODUCE SUBSTANCES THAT FORM RED BLOOD CELLS ERYTHROPOIETIN FLUID AND ELECTROLYTE BALANCE BLOOD PRESSURE CONTROL RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM NRS_105/320 Collings

  5. NRS_105/320 Collings

  6. PHYSIOLOGY OF URINATION BRAIN STRUCTURES THAT INFLUENCE BLADDER EMPTYING CEREBRAL CORTEX, THALAMUS, HYPOTHALAMUS, BRAIN STEM NORMAL VOIDING INVOLVES CONTRACTION OF THE BLADDER MUSCLES AND RELAXATION OF THE URETHRAL SPHINCTER NRS_105/320 Collings

  7. PHYSIOLOGY OF URINATION FACTORS INFLUENCING URINATION AMOUNT OF URINE IN BLADDER ADULT NORMALLY HOLDS 600ML CHILD 150 – 200ML INCREASING URINE VOLUME STIMULATES THE MICTURATION CENTER IN THE SPINAL CORD NORMALLY VOIDING IS A VOLUNTARY PROCESS NRS_105/320 Collings

  8. FACTORS THAT INFLUENCE URINATION PRERENAL DECREASED BLOOD FLOW TO AND THROUGH THE KIDNEYS RENAL DISEASE CONDITIONS OF THE RENAL TISSUE POSTRENAL OBSTRUCTION IN THE LOWER URINARY TRACT NRS_105/320 Collings

  9. DISEASES/ CONDITIONS THAT INFLUENCE URINATION DIABETES – nerve and perfusion changes MULTIPLE SCLEROSIS – nerve changes BPH – BENIGN PROSTATIC HYPERPLASIA - retention COGNITIVE DISORDERS ALZHEIMER’S DISEASE – sensation, cognitive END-STAGE RENAL DISEASE – waste buildup, F & E imbalance [uremic syndrome] REQUIRES DIALYSIS OR TRANSPLANT NRS_105/320 Collings

  10. OTHER FACTORS THAT INFLUENCE URINATION SOCIOCULTURAL FACTORS PRIVACY PSYCHOLOGICAL FACTORS ANXIETY FLUID BALANCE SURGICAL PROCEDURES MEDICATIONS DIAGNOSTIC EXAMINATION NRS_105/320 Collings

  11. Squat toilet – common in Asia, India NRS_105/320 Collings

  12. TERMINOLOGY TO KNOW NRS_105/320 Collings NOCTURIA POLYURIA OLIGURIA DYSURIA ANURIA DIURESIS CYSTITIS HEMATURIA PYLONEPHRITIS INCONTINENCE NOCTURNAL ENURESIS

  13. ALTERATIONS IN URINARY ELIMINATION URINARY RETENTION ACCUMULATION OF URINE RESULTING FROM AN INABILITY OF THE BLADDER TO EMPTY PROPERLY BLADDER UNABLE TO RESPOND TO THE MICTURATION REFLEX NRS_105/320 Collings

  14. ALTERATIONS IN URINARY ELIMINATION • Urinary Retention • POSSIBLE CAUSES: • URETHRAL OBSTRUCTION • SURGICAL TRAUMA • CHILD BIRTH • ALTERATIONS IN SENSORY INNERVATION • ANXIETY • SIDE EFFECTS OF MEDICATIONS NRS_105/320 Collings

  15. ALTERATIONS IN URINARY ELIMINATION URINARY TRACT INFECTIONS (UTIs) MOST COMMON HEALTH CARE ASSOCIATED INFECTION CATHETERIZATION SURGICAL MANIPULATION 75% – 95% CAUSED BY ECOLI NRS_105/320 Collings

  16. ALTERATIONS IN URINARY ELIMINATION • UTI’s - causes • ANY CONDITION RESULTING IN URINARY RETENTION (BPH, swelling/trauma to urethra OR kinked, obstructed or clamped catheter) INCREASES THE RISK OF BLADDER INFECTION • Indwelling catheter [Foley] is a leading cause of UTI and sepsis NRS_105/320 Collings

  17. ALTERATIONS IN URINARY ELIMINATION URINARY INCONTINENCE INVOLUNTARY URINATION CAUSES AGING 50% OF ALL LONG TERM CARE RESIDENTS SUFFER FROM INCONTINENCE COMPLICATIONS SKIN BREAKDOWN NRS_105/320 Collings

  18. ALTERATIONS IN URINARY ELIMINATION URINARY DIVERSION DIVERT URETERS TO ABDOMINAL STOMA CAUSES CANCER OF THE BLADDER TRAUMA RADIATION CHRONIC CYSTITIS NEPHROSTOMY NRS_105/320 Collings

  19. ILEAL CONDUIT NRS_105/320 Collings

  20. NRS_105/320 Collings

  21. Renal Replacement Therapy • Dialysis – can be short or long term • Peritoneal Dialysis: • Indirect; uses osmosis and diffusion • Peritoneum used as semi permeable membrane • Sterile solution [dialysate] instilled into peritoneum by gravity, left for a time, drained out • Hemodialysis • Mechanical filtering of blood via membrane • Blood exits and returns via A/V fistula, CVL NRS_105/320 Collings

  22. Renal Replacement Therapy • Kidney Transplant • Only ‘cure’ – can bring normal kidney function • Living or cadaver donor organ • Piggybacked into abdomen • Requires immunosuppressant medication • Family donation common • Surgery may be more challenging for donor NRS_105/320 Collings

  23. NORMAL URINE VALUES APPEARANCE: clear COLOR: Straw/ Yellow to light amber ODOR: slight ammonia pH: 4.6 – 7.8 PROTEIN: 0 mg/dl SPECIFIC GRAVITY: 1.010 – 1.035 LEUKOCYTES: NEGATIVE NITRITES: NEGATIVE KETONES: NEGATIVE CRYSTALS: NEGATIVE GLUCOSE: NEGATIVE RBC: NEGATIVE WBC: NEGATIVE NORMAL V. ABNORMALURINE NRS_105/320 Collings

  24. ABNORMAL FINDINGS: Implications INCREASED Urine pH RESPIRATORY OR METABOLIC ALKALOSIS GASTRIC SUCTION VOMITING URINARY TRACT INFECTION DECREASED pH METABOLIC ACIDOSIS DIABETES DIARRHEA RESPIRATORY ACIDOSIS NRS_105/320 Collings

  25. ABNORMAL FINDINGS: Implications INCREASED PROTEIN DIABETES CHRONIC HEART FAILURE PREECLAMPSIA GLOMERULONEPHRITIS POLYCYSTIC DISEASE LUPUS ERYTHEMATOUS HEAVY-METAL POISONING BLADDER TUMOR NRS_105/320 Collings

  26. INCREASED SPECIFIC GRAVITY [concentrated] DEHYDRATION GLYCOSURIA, PROTEINURIA FEVER VOMITING DIARRHEA DECREASED SPECIFIC GRAVITY [dilute] OVERHYDRATION RENAL FAILURE HYPOTHERMIA PYELONEPHRITIS ABNORMAL FINDINGS: Implications NRS_105/320 Collings

  27. ABNORMAL FINDINGS: Implications INCREASED RED BLOOD CELLS GLOMERULONEPHRITIS ACUTE TUBULAR NECROSIS CYSTITIS TRAUMATIC BLADDER CATHETERIZATION INCREASED WHITE BLOOD CELLS BACTERIAL INFECTION IN THE URINARY TRACT GLOMERULONEPHRITIS ACUTE PYELONEPHRITIS LUPUS NRS_105/320 Collings

  28. INFECTION CONTROL AND HYGIENE THEURINARY TRACT IS A STERILE ENVIRONMENT APPLY KNOWLEDGE OF MEDICAL AND SURGICAL ASEPSIS WHEN PROVIDING CARE INVOLVING THE URINARY TRACT CATHETERIZATION IS A STERILE TECHNIQUE PERINEAL CARE AND CATHETER CARE IS A CLEAN PROCEDURE NRS_105/320 Collings

  29. PSYCHOSOCIAL CONSIDERATIONS GENDER DIFFERENCES MALES STAND TO URINATE FEMALES SIT TO URINATE HOW MANY PEOPLE LIE DOWN TO URINATE?? Culture variations Privacy, position [squat/sit/stand], gender congruity NRS_105/320 Collings

  30. COMMON URINARY ALTERATIONS URGENCY FREQUENCY HESITANCY RETENTION DRIBBLING INCONTINENCE RESIDUAL URINE NRS_105/320 Collings

  31. DIAGNOSTIC EXAMINATIONS OF THE URINARY SYSTEM OBTAINING A URINE SPECIMEN RANDOM CLEAN CATCH (MIDSTREAM) STERILE TIMED COLLECTION NRS_105/320 Collings

  32. DIAGNOSTIC EXAMINATIONS OF THE URINARY SYSTEM TESTING THE URINE CHEMICAL REAGENT STRIP (DIP STICK) BEDSIDE URINALYSIS pH GLUCOSE BLOOD KETONES PROTEIN Follow instructions [timed] NRS_105/320 Collings

  33. DIAGNOSTIC EXAMINATIONS OF THE URINARY SYSTEM TESTING THE URINE STERILE SPECIMEN STRAIGHT CATHETER ASPIRATE FROM INDWELLING CATHETER SAME PROCEDURE FROM URINARY DIVERSION TIMED SPECIMEN TO BE SENT TO LAB EXAMPLE: 24 HOUR URINE FOR UUN (URINE UREA NITROGEN) SPECIAL CONTAINER MUST SAVE ALL URINE OR START OVER ICE PRESERVATIVE NRS_105/320 Collings

  34. NURSING IMPLICATIONS CLEAN CATCH OR MIDSTREAM ASSEMBLE EQUIPMENT AND INSTRUCT PATIENT ON TECHNIQUE TO OBTAIN SPECIMEN STRAIGHT CATH ASSEMBLE EQUIPMENT EXPLAIN PROCEDURE TO PATIENT INSERT CATHETER USING STERILE TECHNIQUE SEND OBTAINED SPECIMEN TO LAB IN STERILE CONTAINER [5-10ml] NRS_105/320 Collings

  35. NURSING IMPLICATIONS OBTAINING STERILE SPECIMEN FROM EXISTING URINARY CATHETER Clamp catheter for 30 min prior to aspiration to allow fresh urine to gather in tubing Disinfect access port Using syringe [10-15 ml] and large bore needle, access collection port and withdraw 5- 10 ml urine; label, double bag and send to lab Newer catheters have needleless access [Luerlock] May need to change Foley to get true sample NRS_105/320 Collings

  36. NURSING IMPLICATIONS NON-INVASIVE EXAMINATION OF THE BLADDER AND KIDNEYS X-RAY [KUB]– KIDNEYS, URETERS, BLADDER SIMPLE FILM NO PREP DETERMINES SIZE, SHAPE, LOCATION AND SYMMETRY NRS_105/320 Collings

  37. NURSING IMPLICATIONS • NON-INVASIVE EXAMINATION OF THE BLADDER AND KIDNEYS • CT SCAN – • DETAILED IMAGES OF STRUCTURES. TUMORS AND OBSTRUCTIONS MAY BE VISIBLE • PREP: BOWEL CLEANSING • DETERMINE PATIENT ALLERGY TO IODINE (INJECTED DURING PROCEDURE) NRS_105/320 Collings

  38. NURSING IMPLICATIONS NON -INVASIVE EXAMINATION OF KIDNEYS AND BLADDER IVP: INTRAVENOUS PYELOGRAM VIEWS COLLECTING DUCTS, RENAL PELVIS, URETERS, BLADDER AND URETHRA PREP: BOWEL CLEANSING ASSESS PATIENT’S ALLERGY TO IODINE AND SHELLFISH POST TEST ENCOURAGE FLUIDS TO FLUSH DYE FROM SYSTEM MONITOR FOR DELAYED ALLERGIC REACTION NRS_105/320 Collings

  39. NURSING IMPLICATIONS NON-INVASIVE EXAMINATION OF THE KIDNEYS AND BLADDER ULTRASOUND OF THE BLADDER IDENTIFY GROSS RENAL STRUCTURES AND STRUCTURAL ABNORMALITIES NO PREP REQUIRED SIMPLE ULTRASOUND (BLADDER SCAN) CAN BE DONE ON THE NURSING UNIT TO EVALUATE RETAINED URINE (POST VOIDED RESIDUAL – PVR) NRS_105/320 Collings

  40. DIAGNOSTIC EXAMINATIONS OF THE URINARY SYSTEM INVASIVE EXAMINATION OF THE KIDNEYS AND BLADDER CYSTOSCOPY DIRECT VISUALIZATION OF THE BLADDER AND URETHRA SPECIMEN COLLECTION DONE USING CONSCIOUS SEDATION POST PROCEDURE VITAL SIGNS INTAKE AND OUTPUT DESCRIBE URINE ENCOURAGE FLUIDS NRS_105/320 Collings

  41. CATHETER INSERTIONMALE AND FEMALE REQUIRES A PROVIDER ORDER EXPLAIN PROCEDURE TO PATIENT ASSEMBLE EQUIPMENT ASSESS PATIENT Do you need help? Probably! Can [female] pt maintain lithotomy position? Can patient hold still? Keep hands away? This is A STERILE PROCEDURE!! NRS_105/320 Collings

  42. NRS_105/320 Collings

  43. NRS_105/320 Collings

  44. Evidence Based Practice NRS_105/320 Collings • Avoid inserting a catheter • Why is it being done? Document reason, date, time • Use aseptic technique for insertion • Ongoing care • Closed system, bag position • Personal hygiene [soap and water] BID • Catheter care per protocol • Remove promptly [RN or MD decision] (Dailly, 20110

  45. Evidence Based Practice NRS_105/320 Collings • Daily documentation protocols – • date inserted/reason/still needed? • Documentation of peri-care and catheter care • Drainage system [closed system, bag above floor & below bladder] • Computerized reminders, stop dates, RN initiative aid in timely removal of indwelling catheters (Dailly, S. Prevention of Indwelling Catheter-Associated Urinary Tract Infections. Nursing Older People, 23:2; March 2011)

  46. Reasons for Foley Insertion NRS_105/320 Collings • Increased comfort for terminal patients • Management of incontinence • Protection of skin • Measurement of urine in critical patients • Pre- or Post-op bladder drainage • Urinary retention • Urodynamic or Radiologic testing • Bladder treatments [ chemo]

  47. SUPRAPUBIC CATHETERS SURGICAL PLACEMENT OF A CATHETER THROUGH THE ABDOMINAL WALL ABOVE THE SYMPHYSIS PUBIS INTO THE BLADDER APPROPRIATE FOR USE IN PARAPLEGIC, QUADRIPLEGIC AND COMATOSE PATIENTS SLIGHTLY LESS CHANCE FOR INFECTION OVER THE LONG TERM NRS_105/320 Collings

  48. NRS_105/320 Collings

  49. CONDOM CATHETERS FOR MALE PATIENTS ONLY ALTERNATIVE TO CATHETERIZATION LATEX OR SILICONE SHEATH THAT FITS ON PENIS NRS_105/320 Collings

  50. NRS_105/320 Collings

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