Urinary Elimination


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Urinary Elimination

  1. 1. URINARY ELIMINATION <ul><li>Ma. Tosca Cybil A. Torres, RN, MAN </li></ul>
  3. 3. Pretest:
  4. 5. <ul><li>The urinary system consists of organs that produce and excrete urine from the body. </li></ul><ul><li>Urine contains waste: mostly excess water, salts and nitrogen compounds. </li></ul><ul><li>Primary organs are the kidneys </li></ul><ul><li>Normal adult bladder can store up to .5 liters. </li></ul><ul><li>Also responsible for regulating blood volume and blood pressure. </li></ul><ul><li>Regulates electrolytes. </li></ul>
  5. 6. Organs of the Urinary System <ul><li>The components of the urinary system include : </li></ul><ul><li>the kidneys </li></ul><ul><li>the ureters </li></ul><ul><li>the urinary bladder </li></ul><ul><li>the urethra. </li></ul>
  6. 7. Kidneys <ul><li>The kidneys are bean-shaped organs located at the back of the abdominal cavity. </li></ul><ul><li>They lie on either side of the spinal column. </li></ul><ul><li>This area is known as the flank area and is against the muscles of the back. </li></ul><ul><li>The external kidney has a notch at the concave border known as the hilum. </li></ul><ul><li>The hilum is the entrance for renal artery, veins, nerves and lymphatic vessels. </li></ul>
  7. 8. Internal Structure of the Kidney <ul><li>The cortex is the outer layer; arteries, veins, convoluted tubes and glomerular capsules </li></ul><ul><li>The medulla is the inner layer; renal pyramids </li></ul>
  8. 9. Nephrons <ul><li>1 million nephrons </li></ul><ul><li>The functional unit of the kidney </li></ul><ul><li>Remove waste products of metabolism from the blood plasma. </li></ul><ul><li>Waste products are urea, uric acid, creatinine, sodium, potassium chloride and ketone bodies. </li></ul>
  9. 10. Urine formation:
  10. 11. Ureters, bladder and urethra <ul><li>Ureters -tubes that carry newly formed urine from the bladder to the kidneys. </li></ul><ul><li>Bladder -muscular sac that serves as a reservoir for urine; bladder stretches to accommodate urine. </li></ul><ul><li>Urethra - tube extends from the bladder to the external opening of the urinary system, the urinary meatus </li></ul>
  11. 12. Urine <ul><li>The formation of urine has 3 processes, filtration, reabsorption and tubular secretion. </li></ul><ul><li>Urine consists of 95% water and 5% solid substances. </li></ul><ul><li>The need to urinate is usually felt at 300-350ml of urine in the bladder. </li></ul><ul><li>Typically 1000-1500 mL is voided daily. </li></ul>
  12. 13. Physical Characteristics of Urine <ul><li>Odor </li></ul><ul><ul><li>Fresh urine is slightly aromatic </li></ul></ul><ul><ul><li>Standing urine develops an ammonia odor </li></ul></ul><ul><ul><li>Some drugs and vegetables (asparagus) alter the usual odor </li></ul></ul>
  13. 14. Physical Characteristics of Urine <ul><li>pH </li></ul><ul><ul><li>Slightly acidic (pH 6) with a range of 4.5 to 8.0 </li></ul></ul><ul><ul><li>Diet can alter pH </li></ul></ul><ul><li>Specific gravity </li></ul><ul><ul><li>Ranges from 1.010 to 1.025 </li></ul></ul><ul><ul><li>Dependent on solute concentration </li></ul></ul>
  14. 15. Chemical Characteristics of Urine <ul><li>Urine is 95% water and 5% solutes </li></ul><ul><li>Nitrogenous wastes (organic solutes) include urea, ammonia, uric acid, and creatinine </li></ul><ul><li>Other normal solutes include: </li></ul><ul><ul><li>Sodium, potassium, phosphate, and sulfate ions </li></ul></ul><ul><ul><li>Calcium, magnesium, and bicarbonate ions </li></ul></ul><ul><li>NaCl is the most abundant inorganic salt in the urine. </li></ul><ul><li>Urea is the chief organic solute. </li></ul><ul><li>Abnormally high concentrations of any urinary constituents may indicate pathology </li></ul><ul><li>Disease states alter urine composition dramatically </li></ul>
  15. 16. Lifespan considerations <ul><li>Child </li></ul><ul><li>At 10 weeks gestation the kidney begin to form </li></ul><ul><li>Newborns kidneys are not able to concentrate urine </li></ul><ul><li>Kidneys are more susceptible to trauma </li></ul><ul><li>Diapers- more susceptible to UTI </li></ul><ul><li>Older Adult </li></ul><ul><li>Kidney lose mass and the blood vessels degenerate </li></ul><ul><li>Kidneys lose their ability to filter </li></ul><ul><li>Dehydration can happen more quickly </li></ul><ul><li>Electrolyte balance happens more quickly </li></ul><ul><li>Loss of muscles tome in urinary structures </li></ul><ul><li>Decreased bladder capacity </li></ul>
  16. 17. Urination <ul><li>Micturation, voiding, and urination all refer to the process of emptying the urinary bladder </li></ul><ul><li>Stretch receptors- special sensory nerve endings in the bladder wall that is stimulated when pressure is felt from the collection of urine </li></ul><ul><ul><li>Adult: 250-450mL of urine </li></ul></ul><ul><ul><li>Children: 50-200mL of urine </li></ul></ul>
  17. 18. Factors affecting voiding <ul><li>Growth and development </li></ul><ul><li>Psychosocial factors </li></ul><ul><li>Fluid and food intake </li></ul><ul><li>Medications </li></ul><ul><li>Muscle tone and activity </li></ul><ul><li>Pathologic conditions </li></ul><ul><li>Surgical and diagnostic procedures </li></ul>
  18. 19. Altered Urine Production <ul><li>Polyuria- a.k.a. diuresis </li></ul><ul><ul><li>production of abnormally large amounts of urine by the kidneys </li></ul></ul><ul><ul><li>2500mL/day for adults </li></ul></ul><ul><ul><li>Causes: </li></ul></ul><ul><ul><ul><li>Excessive fluid intake </li></ul></ul></ul><ul><ul><ul><li>Intake of alcohol and caffeine </li></ul></ul></ul><ul><ul><ul><li>Diabetes mellitus </li></ul></ul></ul><ul><ul><ul><li>Hormone imbalances </li></ul></ul></ul><ul><ul><ul><li>CKD </li></ul></ul></ul><ul><ul><li>Other signs associated with diuresis: polydipsia, dehydration and weight loss </li></ul></ul>
  19. 20. Oliguria <ul><li>Voiding scant amounts of urine </li></ul><ul><li>Less than 500mL/day </li></ul><ul><li>Anuria </li></ul><ul><li>Voiding less than 100mL/day </li></ul><ul><li>May result from low fluid intake, kidney disease, severe heart failure, burns and shock </li></ul><ul><li>Usually accompanied by fever and heavy respiration </li></ul>
  20. 21. Altered urinary Elimination <ul><li>Frequency - voiding at frequent intervals that is more often than usual. </li></ul><ul><li>Total amount of urine voided may be normal but amount of each voiding are small---50-100mL </li></ul><ul><li>May result from increased fluid intake, cystitis, stress, or pressure on the bladder </li></ul><ul><li>Nocturia or nycturia- increased frequency at night that is not a result of an increased fluid intake </li></ul><ul><li>Expressed in terms number of times the person gets out of bed to void </li></ul>
  21. 22. Altered urinary Elimination <ul><li>Urgency- feeling that the person must void. </li></ul><ul><li>Usually accompanies psychologic stress, and irritation of the urethra </li></ul><ul><li>Common in young children who have poor external sphincter control </li></ul><ul><li>Dysuria- voiding that is either painful or difficult </li></ul><ul><li>May result from stricture of the urethra, urinary infections, injury to the bladder and/ or the urethra. </li></ul><ul><li>Described as a burning sensation during voiding </li></ul><ul><li>Burning during micturation if often due to an irritated urethra. Burning following urination may be a result of bladder infection </li></ul><ul><li>Often associated with urinary hesitancy (delay and difficulty in initiating voiding) </li></ul>
  22. 23. Altered urinary Elimination <ul><li>Enuresis - repeated involuntary urination in children beyond the age when voluntary bladder control in normally acquired (4-5yrs) </li></ul>
  23. 24. <ul><li>Urinary incontinence- is considered a symptom, not a disease. </li></ul><ul><li>Types: </li></ul><ul><li>Functional incontinence- involuntary unpredictable passage of urine </li></ul><ul><li>Reflex incontinence- involuntary loss of urine occurring at somewhat predictable intervals when a specific bladder volume is reached. </li></ul><ul><li>Stress incontinence- loss of urine of less than 50cc occurring with increased intra-abdominal pressure </li></ul><ul><li>Total incontinence- continuous and unpredictable loss of urine. </li></ul><ul><li>Urge incontinence- involuntary passage of urine occuring soon after a strong sense of urgency to void. </li></ul><ul><li>* urinary retention with overflow- dribbling incontinence that results when the bladder is greatly distended with urine because of an obstruction </li></ul><ul><li>Neurogenic bladder- describes any voiding problem related to neurologic impairment or dysfunction. </li></ul>Altered urinary Elimination
  24. 25. Altered urinary Elimination <ul><li>Urinary retention- accumulation of urine in the bladder (as much as 3L) with associated inability of the bladder to empty itself. </li></ul><ul><li>Adult- can hold 250-450ml of urine in the bladder before micturation reflex in triggered. </li></ul><ul><li>Prolonged retention leads to stasis (slowing of the flow of urine) and stagnation of urine which increases the possibility of UTI. </li></ul><ul><li>Retention if distinguished from oliguria or anuria by the distention of the bladder. </li></ul><ul><li>Characterized by small, frequent voiding or absence of urine output </li></ul>
  25. 26. Assessment <ul><li>Nursing history </li></ul><ul><li>Data about voiding patterns and habits, any problems voiding, and past or present problems involving the urinary system </li></ul><ul><li>Data about any problems that may affect urination </li></ul>
  26. 27. Collecting urine specimens <ul><li>Clean catch or midstream specimens must be free as possible from external contamination by MO near the urethral opening. </li></ul><ul><li>About 120ml of urine is generally required for examination. </li></ul><ul><li>General guidelines: </li></ul><ul><li>The specimen must be free of fecal contamination </li></ul><ul><li>Female clients should discard toilet tissue in the toilet or trash bins rather than in the bedpan </li></ul><ul><li>Put lid tightly on the container to prevent spillage of the urine and contamination of other objects </li></ul><ul><li>If the outside of the container has been contaminated, clean it with a disinfectant. </li></ul>
  27. 28. Collecting a Timed Urine Specimen <ul><li>May short periods (1-2hrs) or long periods (12-24hrs) </li></ul><ul><li>Steps: </li></ul><ul><li>Place alert signs about the specimen collection at the client’s bedside or bathroom </li></ul><ul><li>Label specimen containers to include date and time of each voiding as well as the usual client ID data. Containers may be numbered sequentially </li></ul><ul><li>Explain to the client the purpose of the test, when it begins, or what to do with it. </li></ul>
  28. 29. Measuring Residual Urine <ul><li>residual urine- urine remaining in the bladder following the voiding </li></ul><ul><li>Purposes of measuring residual urine: </li></ul><ul><li>To determine the degree to which the bladder is emptying </li></ul><ul><li>Assess the need to establish therapy that will empty the bladder. </li></ul><ul><li>* To measure the residual urine, the nurse asks the client to void then immediately catheterizes the client. </li></ul>
  29. 30. Diagnostic tests <ul><li>Urinalysis </li></ul><ul><li>Blood tests: (BUN and Creatinine clearance) </li></ul><ul><li>Cystoscopy </li></ul><ul><li>Intravenous pyelogram (IVP)/ excretory pyelogram </li></ul><ul><li>Retrograde pyelogram </li></ul><ul><li>CAT scan </li></ul><ul><li>UTZ </li></ul>
  30. 31. Diagnosing: <ul><li>Possible nursing diagnoses: </li></ul><ul><li>Incontinence </li></ul><ul><ul><li>Functional incontinence </li></ul></ul><ul><ul><li>Reflex incontinence </li></ul></ul><ul><ul><li>Stress incontinence </li></ul></ul><ul><ul><li>Total incontinence </li></ul></ul><ul><ul><li>Urge incontinence </li></ul></ul><ul><li>Altered urinary elimination </li></ul><ul><li>Urinary retention </li></ul><ul><li>High risk for infection </li></ul><ul><li>Self-esteem disturbance </li></ul><ul><li>High risk for impaired skin integrity </li></ul><ul><li>Social isolation </li></ul><ul><li>Self care deficit: toileting </li></ul>
  31. 32. Implementing <ul><li>Maintaining Normal Urinary Elimination </li></ul><ul><li>Promoting normal fluid intake </li></ul><ul><li>Maintaining normal voiding habits </li></ul><ul><ul><li>Relaxation </li></ul></ul><ul><ul><ul><li>Provide privacy </li></ul></ul></ul><ul><ul><ul><li>Allow client sufficient time to void </li></ul></ul></ul><ul><ul><ul><li>Suggest the client to read or listen to music </li></ul></ul></ul><ul><ul><ul><li>Provide sensory stimuli </li></ul></ul></ul><ul><ul><ul><li>Pour warm water over perineum or have the client sit in a warm bath to promote muscle relaxation </li></ul></ul></ul><ul><ul><ul><li>Apply hot-water bottle to the lower abdomen </li></ul></ul></ul><ul><ul><ul><li>Turn on running water within hearing distance </li></ul></ul></ul><ul><ul><ul><li>Relieve physical or emotional discomfort </li></ul></ul></ul><ul><ul><li>Timing </li></ul></ul><ul><ul><ul><li>Assist clients to have the urge to void immediately </li></ul></ul></ul><ul><ul><ul><li>Offer toileting assistance at usual times of voiding </li></ul></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><ul><li>Assist client in a normal position for voiding </li></ul></ul></ul><ul><ul><ul><li>Use bedside commodes as necessary for females and urinals for males standing at bedside </li></ul></ul></ul><ul><ul><ul><li>Encourage client to push over the pubic area with hands or to lean forward </li></ul></ul></ul>
  32. 33. Managing Urinary Incontinence (UI) <ul><li>Continence (bladder) training </li></ul><ul><li>Bladder training- requires that the client postpone voiding, resist or inhibit the sensation urgency, and void according to a timetable rather than according to the urge to void. The goal is to lengthen the intervals between urination to correct the client’s habit of frequent urination </li></ul><ul><li>Habit training- also referred to as timed voiding or scheduled toileting. There is no attempt to motivate the client to delay voiding is the urge occurs. </li></ul><ul><li>Prompt voiding- supplements the habit training by encouraging the client to use the toilet and reminding the client when to void </li></ul>
  33. 34. Pelvic Muscle Exercises (PME) <ul><li>Referred to as perineal muscle tightening or Kegel’s exercises </li></ul><ul><li>Streghthen pubococcygeal muscles and can increase the incontinent female’s ability to start and stop the stream of urine </li></ul>Managing Urinary Incontinence (UI)
  34. 35. Managing Urinary Incontinence (UI) <ul><li>Positive reinforcements </li></ul><ul><li>Maintaining skin integrity </li></ul><ul><li>Applying external urinary devices </li></ul>
  35. 36. Managing Urinary Retention <ul><li>Urinary catheterization </li></ul>