Basic Human Basic Human NeedsNeeds

Urinary EliminationUrinary Elimination

Urinary EliminationUrinary Elimination Basic function that is taken for Basic function that is taken for

grantedgranted When the urinary system fails to When the urinary system fails to

function properly, all organ systems function properly, all organ systems will be affectedwill be affected

Urinary elimination depends on the Urinary elimination depends on the function of the kidneys, ureters, function of the kidneys, ureters, bladder, & urethrabladder, & urethra

KidneysKidneys Paired, reddish, brown bean shaped Paired, reddish, brown bean shaped

organsorgans Location: 12Location: 12thth thoracic vertebrae to 3 thoracic vertebrae to 3rdrd

LumbarLumbar Left kidney is 1.5 to 2 cm higher than Left kidney is 1.5 to 2 cm higher than

right, 12 x 7 cmright, 12 x 7 cm Weight: 120-150 gmsWeight: 120-150 gms Covered by tough capsule and cushioned Covered by tough capsule and cushioned

by fatby fat

KidneysKidneys Waste products filtered through Waste products filtered through

kidneyskidneys Blood reached kidney via renal Blood reached kidney via renal

arteryartery 20-25% of cardiac output circulates 20-25% of cardiac output circulates

to kidneys (1200ml/min)to kidneys (1200ml/min)

Anatomy of KidneyAnatomy of Kidney Nephron-Functional unit of kidney, forms Nephron-Functional unit of kidney, forms

urineurine Each kidney has 1 million nephronsEach kidney has 1 million nephrons Nephron composed of glomerulus, Nephron composed of glomerulus,

Bowman’s capsule, proximal convoluted Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal tubule, & tubule, loop of Henle, distal tubule, & collecting tubulecollecting tubule

Blood SupplyBlood Supply Blood reaches kidney via renal Blood reaches kidney via renal

arteryartery Arises from aorta, enters kidney at Arises from aorta, enters kidney at

hilushilus Renal artery divides into secondary Renal artery divides into secondary

branches, then into smaller braches branches, then into smaller braches to afferent arterioleto afferent arteriole

Blood SupplyBlood Supply To Kidney: Afferent arteriole divides into To Kidney: Afferent arteriole divides into

a capillary network called glomerulusa capillary network called glomerulus From Kidney: The capillaries unite to form From Kidney: The capillaries unite to form

the Efferent arteriole which splits to form the Efferent arteriole which splits to form peritubular capillaries, drain into venous peritubular capillaries, drain into venous system > renal vein > inferior vena cava system > renal vein > inferior vena cava > heart> heart

Physiology of Urine Physiology of Urine FormationFormation

Normal glomerular function- Urine Normal glomerular function- Urine formation starts at glomerulus where formation starts at glomerulus where blood is filteredblood is filtered

GFR-(Glomerular filtration rate)- amt of GFR-(Glomerular filtration rate)- amt of blood filtered by glomeruli in a given timeblood filtered by glomeruli in a given time

Normal GFR- 125ml/minute, however only Normal GFR- 125ml/minute, however only 1 ml per minute becomes urine, most is 1 ml per minute becomes urine, most is reabsorbedreabsorbed

Tubular FunctionTubular Function ReabsorptionReabsorption-refers to the passage of a -refers to the passage of a

substance from the lumen of the tubules substance from the lumen of the tubules through the tubule cells and into the through the tubule cells and into the capillariescapillaries

Tubular SecretionTubular Secretion-passage of a substance -passage of a substance from the capillaries through the tubular from the capillaries through the tubular cells and into the lumen of the tubulecells and into the lumen of the tubule

Tubular FunctionTubular Function Proximal Convoluted Tubule- 80% of Proximal Convoluted Tubule- 80% of

electrolytes, glucose, amino acids, electrolytes, glucose, amino acids, protein, reabsorbed Hydrogen & protein, reabsorbed Hydrogen & creatinine are secreted into filtratecreatinine are secreted into filtrate

Loop of Henle - Important in conserving Loop of Henle - Important in conserving water, reabsorption continues, water, reabsorption continues, Descending loop-reabsorption of HDescending loop-reabsorption of H22O, O, Ascending loop- reabsorption of Na & ClAscending loop- reabsorption of Na & Cl

Tubular FunctionTubular Function Distal Convoluted Tubule- Final regulation Distal Convoluted Tubule- Final regulation

of water balance & acid-base balance. of water balance & acid-base balance. Requires ADH (anti-diuretic hormone) for Requires ADH (anti-diuretic hormone) for water reabsorption & aldosterone for Na water reabsorption & aldosterone for Na & Cl reabsorption& Cl reabsorption

Stimulus for ADH secretion: high serum Stimulus for ADH secretion: high serum osmolality, low blood volumeosmolality, low blood volume

Aldosterone secretion influenced by Aldosterone secretion influenced by circulating blood volume, plasma circulating blood volume, plasma concentration of Na &Clconcentration of Na &Cl

Tubular FunctionTubular Function Distal Tubule: Acid-Base regulation Distal Tubule: Acid-Base regulation

involves reabsorbing and conserving involves reabsorbing and conserving Bicarb and excretion of excess hydrogen Bicarb and excretion of excess hydrogen to maintain blood pH at 7.35-7.45to maintain blood pH at 7.35-7.45

99% of filtrate is reabsorbed into plasma, 99% of filtrate is reabsorbed into plasma, 1% excreted as urine1% excreted as urine

Normal 24 hr urine output is 1500-1600mlNormal 24 hr urine output is 1500-1600ml

Hormone ProductionHormone Production ErythropoietinErythropoietin ReninRenin AngiotensinogenAngiotensinogen Kidneys also play a role in Calcium Kidneys also play a role in Calcium

& Phosphate regulation,convert & Phosphate regulation,convert Vitamin D to active formVitamin D to active form

UretersUreters Enter renal pelvis from collecting ductsEnter renal pelvis from collecting ducts A ureter joins each renal pelvis to bladderA ureter joins each renal pelvis to bladder Tubular structures, 10-12 cm longTubular structures, 10-12 cm long Peristaltic waves move urine to bladderPeristaltic waves move urine to bladder Obstruction of ureters-renal calculi, Obstruction of ureters-renal calculi,

strong peristaltic wave-renal colicstrong peristaltic wave-renal colic

BladderBladder Hollow,distensible, muscular organ (4 Hollow,distensible, muscular organ (4

layers of muscle)layers of muscle) Reservoir for urineReservoir for urine Organ of excretionOrgan of excretion Expands as it becomes filled with urineExpands as it becomes filled with urine Pressure within bladder is lowPressure within bladder is low 600ml capacity, normal voiding 300ml600ml capacity, normal voiding 300ml

BladderBladder Trigone-base of bladderTrigone-base of bladder Muscular layer-detrusor muscleMuscular layer-detrusor muscle Parasympathetic innervation Parasympathetic innervation

stimulates detrusor during urination stimulates detrusor during urination (smooth muscle contraction) (smooth muscle contraction) resulting in bladder emptyingresulting in bladder emptying

BladderBladder External Sphincter control under External Sphincter control under

voluntary controlvoluntary control Sympathetic innervation cause smooth Sympathetic innervation cause smooth

muscle relaxation allowing bladder to fillmuscle relaxation allowing bladder to fill Internal Sphincter (involuntary) Internal Sphincter (involuntary)

controlled by SNS- cause urethrea to controlled by SNS- cause urethrea to remain closed until person is ready to voidremain closed until person is ready to void

Control of Micturition is a result of Control of Micturition is a result of coordination between the opening of the coordination between the opening of the sphincters and contraction of detrusorsphincters and contraction of detrusor

UrethraUrethra Urine travels from the bladder through Urine travels from the bladder through

the urethra & passes outside the body the urethra & passes outside the body through the urethral meatusthrough the urethral meatus

Lined by mucus membranes, Lined by mucus membranes, bacteriostatic, forms mucus plugbacteriostatic, forms mucus plug

Women-1.5-2.5 inches long, external Women-1.5-2.5 inches long, external sphincter allows voluntary flow of urine, sphincter allows voluntary flow of urine, prone to infectionprone to infection

UrethraUrethra Men-Urethra is both a urinary canal Men-Urethra is both a urinary canal

and a passageway for secretions and a passageway for secretions form reproductive organsform reproductive organs

20cm in length20cm in length

Clicker QuestionClicker Question

1.1. A client with long-standing history A client with long-standing history of diabetes mellitus is voicing concerns of diabetes mellitus is voicing concerns about kidney disease. The client asks about kidney disease. The client asks the nurse where urine is formed in the the nurse where urine is formed in the kidney. The nurse’s response is the:kidney. The nurse’s response is the:

A.A. GlomerulusGlomerulus B.B. KidneyKidney C.C. NephronNephron D.D. UreterUreter

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Act of UrinationAct of Urination Controlled by brainControlled by brain Coordination of cerebral cortex, Coordination of cerebral cortex,

thalamus, hypothalamus, & brain thalamus, hypothalamus, & brain stemstem

Suppress contraction of bladder’s Suppress contraction of bladder’s detrusor until person is ready to voiddetrusor until person is ready to void

Act of UrinationAct of Urination Bladder normally holds as much as 600 ml Bladder normally holds as much as 600 ml

of urineof urine Desire to void is felt(sensed) when Desire to void is felt(sensed) when

bladder contains a smaller amount (150-bladder contains a smaller amount (150-200ml in adult)200ml in adult)

As bladder volume increases, bladder As bladder volume increases, bladder walls stretch, sending sensory impulses to walls stretch, sending sensory impulses to micturition center in sacral spinal cordmicturition center in sacral spinal cord

Act of UrinationAct of Urination Parasympathetic impulses from the Parasympathetic impulses from the

micturition center stimulate detrusor micturition center stimulate detrusor muscle to contractmuscle to contract

Internal sphincter relaxes so urine can Internal sphincter relaxes so urine can enter urethraenter urethra

As bladder contracts, nerve impulses As bladder contracts, nerve impulses travel up spinal cord to the cerebral travel up spinal cord to the cerebral cortex, now you are aware of the urge to cortex, now you are aware of the urge to voidvoid

Factors Influencing Factors Influencing UrinationUrination

DiseaseDisease Growth & DevelopmentGrowth & Development Sociocultural factorsSociocultural factors Psychological FactorsPsychological Factors Muscle ToneMuscle Tone Fluid BalanceFluid Balance SurgerySurgery MedicationsMedications

DiseaseDisease Pre-renalPre-renal

RenalRenal

Post-renalPost-renal

Pre-Renal DiseasePre-Renal Disease Alterations in urinary elimination Alterations in urinary elimination

resulting from a decrease in resulting from a decrease in circulating blood flow to and circulating blood flow to and through the kidneys with a resultant through the kidneys with a resultant decrease in perfusion to renal tissuedecrease in perfusion to renal tissue

Alteration is outside the urinary Alteration is outside the urinary systemsystem

Pre-Renal DiseasePre-Renal Disease Decrease in renal perfusion leads to Decrease in renal perfusion leads to

oliguria (diminished capacity to form oliguria (diminished capacity to form urine) or anuria (inability to produce urine) or anuria (inability to produce urine)urine)

Pre-renal ConditionsPre-renal Conditions Decreased intravascular volumeDecreased intravascular volume DehydrationDehydration HemorrhageHemorrhage ShockShock SepsisSepsis Anaphylactic ReactionsAnaphylactic Reactions Cardiac Pump FailureCardiac Pump Failure

Renal DiseaseRenal Disease Result from factors that cause injury Result from factors that cause injury

directly to glomeruli or renal tubule, directly to glomeruli or renal tubule, interfering with normal filtration, interfering with normal filtration, reabsorption, & secretory functionsreabsorption, & secretory functions

Renal ConditionsRenal Conditions Nephrotoxic agents (aminoglycoside Nephrotoxic agents (aminoglycoside

antibiotics)antibiotics) Blood transfusion reactionBlood transfusion reaction Disease of glomeruliDisease of glomeruli Renal tumorsRenal tumors Systemic disease (Diabetes)Systemic disease (Diabetes) InfectionInfection Hereditary disease (Polycystic kidney Hereditary disease (Polycystic kidney

disease)disease)

Post-Renal diseasePost-Renal disease Result from obstruction of urinary Result from obstruction of urinary

collecting system from kidney to collecting system from kidney to urethral meatusurethral meatus

Urine is formed but cannot be Urine is formed but cannot be eliminatedeliminated

Post-Renal ConditionsPost-Renal Conditions Obstruction due to calculi, blood Obstruction due to calculi, blood

clots, tumors, or strictureclots, tumors, or stricture Prostatic hypertrophy or tumorProstatic hypertrophy or tumor Neurogenic bladderNeurogenic bladder Pelvic tumorsPelvic tumors

Renal DiseaseRenal Disease Diseases that cause irreversible Diseases that cause irreversible

damage to the glomerulus or tubules damage to the glomerulus or tubules result in permanent alterations in result in permanent alterations in renal functionrenal function

Chronic Renal DiseaseChronic Renal Disease End Stage Renal DiseaseEnd Stage Renal Disease Needs treatment for survivalNeeds treatment for survival

Uremic SyndromeUremic Syndrome Decreased urine outputDecreased urine output ProteinuriaProteinuria Volume overload Volume overload CHFCHF DysrhythmiasDysrhythmias N/VN/V Uremic frostUremic frost AnemiaAnemia

Renal Disease LabsRenal Disease Labs Elevated BUN (7-26 mg/dl)Elevated BUN (7-26 mg/dl) Elevated creatinine (0.7-1.5 mg/dl)Elevated creatinine (0.7-1.5 mg/dl) Elevated potassium (3.5-5.1 Elevated potassium (3.5-5.1

mmol/L)mmol/L) Elevated phosphate (2.4-4.4 mg/dl)Elevated phosphate (2.4-4.4 mg/dl) Decreased calcium (8.6-10.6 mg/dl)Decreased calcium (8.6-10.6 mg/dl) Decreased HCO3 and pH (22-26, Decreased HCO3 and pH (22-26,

7.35-7.45)7.35-7.45)

Uremic SyndromeUremic Syndrome Increase in nitrogen waste in bloodIncrease in nitrogen waste in blood Fluid and electrolyte disturbanceFluid and electrolyte disturbance Treatment either conservative or Treatment either conservative or

aggressiveaggressive

Renal Disease TreatmentRenal Disease Treatment

Conservative- meds, diet & fluid Conservative- meds, diet & fluid restrictionrestriction

Aggressive- Renal Replacement Aggressive- Renal Replacement Therapies: Dialysis (Peritoneal or Therapies: Dialysis (Peritoneal or Hemodialysis) Hemodialysis)

Organ transplantationOrgan transplantation

DialysisDialysis Peritoneal-Indirect method of Peritoneal-Indirect method of

cleansing blood of waste products cleansing blood of waste products using the process of osmosis and using the process of osmosis and diffusiondiffusion

Hemodialysis-machine process Hemodialysis-machine process utilizes osmosis, diffusion, & utilizes osmosis, diffusion, & ultrafiltration through a vascular ultrafiltration through a vascular graft (Udall, TESIO, Permcath, graft (Udall, TESIO, Permcath, Shiley)Shiley)

Index

                                                                 

Organ TransplantationOrgan Transplantation Replacement of diseased kidney with Replacement of diseased kidney with

a healthy onea healthy one Compatible blood and tissue typeCompatible blood and tissue type Sharing NetworkSharing Network Organ Donation cardOrgan Donation card

Factors Influencing Factors Influencing Urination: Urination:

G & DG & D Infants & young children cannot Infants & young children cannot

effectively concentrate their urineeffectively concentrate their urine Older adult: difficulty with urination, Older adult: difficulty with urination,

GFR declines. Kidney’s ability to GFR declines. Kidney’s ability to concentrate urine declinesconcentrate urine declines

Nocturia, urinary frequencyNocturia, urinary frequency BPH in menBPH in men Residual urine (UTI’s)Residual urine (UTI’s)

Factors Influencing Factors Influencing Urination:SocioculturalUrination:Sociocultural

Private toilet facilities (American) Private toilet facilities (American) communal (Europe)communal (Europe)

Social expectations influence time of Social expectations influence time of urinationurination

Must consider cultural, social and Must consider cultural, social and gender habitsgender habits

Factors Influencing Factors Influencing Urination: PsychologicalUrination: Psychological

Anxiety and emotional stress may Anxiety and emotional stress may cause sense of urgency and increase cause sense of urgency and increase frequency of urinationfrequency of urination

Need to relax to voidNeed to relax to void

Factors Influencing Factors Influencing Urination: Muscle ToneUrination: Muscle Tone

Weak abdominal & pelvic floor Weak abdominal & pelvic floor muscles impair bladder contraction muscles impair bladder contraction and control of external sphincterand control of external sphincter

Prolonged immobility, stretching of Prolonged immobility, stretching of muscles, menopausal muscle muscles, menopausal muscle atrophy, damage from trauma, long atrophy, damage from trauma, long term catheter useterm catheter use

Factors Influencing Factors Influencing Urination: Fluid BalanceUrination: Fluid Balance

Ingested fluids increase body’s circulating Ingested fluids increase body’s circulating plasma volume which increase urine plasma volume which increase urine outputoutput

Increased urine formation: coffee, tea, Increased urine formation: coffee, tea, cola drinks cola drinks

Caffeine is a bladder irritant as well as a Caffeine is a bladder irritant as well as a diureticdiuretic

Alcohol inhibits the release of ADH Alcohol inhibits the release of ADH resulting in increased water loss in urineresulting in increased water loss in urine

Factors Influencing Factors Influencing Urination: SurgeryUrination: Surgery

Triggers General Adaptation Syndrome Triggers General Adaptation Syndrome ( Increase water reabsorption, reduces ( Increase water reabsorption, reduces urine outputurine output

Stress response causes increased Stress response causes increased aldosterone resulting in decreased urine aldosterone resulting in decreased urine outputoutput

Anesthetics & narcotics slow GFR Anesthetics & narcotics slow GFR decreasing urine output, risk for urinary decreasing urine output, risk for urinary retention with spinal anesthesia (post-op retention with spinal anesthesia (post-op patients may require hourly urine outputs patients may require hourly urine outputs or if unable to void after surgery, straight or if unable to void after surgery, straight catheterization)catheterization)

Factors Influencing Factors Influencing Urination: MedicationsUrination: Medications

Diuretics prevent reabsorption of Diuretics prevent reabsorption of water and certain electrolytes to water and certain electrolytes to increase urine outputincrease urine output

Urinary retention caused by Urinary retention caused by antihistamines (Sudafed), antihistamines (Sudafed), antihypertensives (Aldomet), & beta antihypertensives (Aldomet), & beta blockers (Inderal)blockers (Inderal)

Change color of urine-PyridiumChange color of urine-Pyridium

Clicker QuestionClicker Question

A young girl is having problems A young girl is having problems urinating postoperatively. You urinating postoperatively. You remember that children may have remember that children may have trouble voiding:trouble voiding:

A.A. In bathrooms other than their ownIn bathrooms other than their own B.B. In a urinalIn a urinal C.C. While lying in bedWhile lying in bed D.D. In the presence of person other In the presence of person other

than their parentsthan their parents

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Alterations in Urinary Alterations in Urinary EliminationElimination

Urinary RetentionUrinary Retention

Urinary Tract InfectionsUrinary Tract Infections

Urinary IncontinenceUrinary Incontinence

Urinary DiversionsUrinary Diversions

Urinary RetentionUrinary Retention Marked accumulation of urine in bladder Marked accumulation of urine in bladder

as a result of the inability of the bladder as a result of the inability of the bladder to emptyto empty

Bladder not able to respond to micturition Bladder not able to respond to micturition reflex and emptyreflex and empty

Retention with overflow may develop, Retention with overflow may develop, small amt of urine escapes, bladder small amt of urine escapes, bladder spasmsspasms

S&S of bladder distention- discomfort, S&S of bladder distention- discomfort, diaphoresis, restlessnessdiaphoresis, restlessness

Lower Urinary Tract Lower Urinary Tract InfectionInfection

7 million office visits a year7 million office visits a year Most common nosocomial infection Most common nosocomial infection

on U.S.on U.S. Most from catheterization or surgeryMost from catheterization or surgery Bacteria in the urine may lead to the Bacteria in the urine may lead to the

spread of organisms into spread of organisms into bloodstream (Urosepsis)bloodstream (Urosepsis)

UTI SymptomsUTI Symptoms Pain or burning on urination Pain or burning on urination

(dysuria)(dysuria) Fever, chills, n/v, malaise (later Fever, chills, n/v, malaise (later

signs)signs) Hematuria-irritation of bladder & Hematuria-irritation of bladder &

urethral mucosa resulting in blood-urethral mucosa resulting in blood-tinged urinetinged urine

Pyelonephritis-infection spreads up Pyelonephritis-infection spreads up to kidney-flank pain, feverto kidney-flank pain, fever

Urinary IncontinenceUrinary Incontinence Involuntary loss of urine that is a Involuntary loss of urine that is a

sufficient problemsufficient problem Temporary or PermanentTemporary or Permanent No longer have control over No longer have control over

micturitionmicturition Leakage can be intermittent or Leakage can be intermittent or

continuouscontinuous

Urinary IncontinenceUrinary Incontinence FunctionalFunctional OverflowOverflow ReflexReflex StressStress UrgeUrge

Urinary DiversionsUrinary Diversions Urinary stoma to divert urine from Urinary stoma to divert urine from

kidneys directly to abdominal kidneys directly to abdominal surfacesurface

Ileal ConduitIleal Conduit Continent PouchContinent Pouch UreterostomyUreterostomy NephrostomyNephrostomy

Reasons for DiversionsReasons for Diversions Cancer (Bladder, Prostate, Pelvis, Cancer (Bladder, Prostate, Pelvis,

Cervix)Cervix) Radiation injuryRadiation injury Vesicovaginal fistulaVesicovaginal fistula Neurogenic bladderNeurogenic bladder Chronic cystitisChronic cystitis Painful Bladder Painful Bladder

Syndrome/Interstitial CystitisSyndrome/Interstitial Cystitis

Clicker QuestionClicker Question

A health care provider may suspect that a A health care provider may suspect that a client is experiencing urinary retention client is experiencing urinary retention when the client has:when the client has:

A.A. Large amounts of voided cloudy urineLarge amounts of voided cloudy urine B.B. Pain in the suprapubic regionPain in the suprapubic region C.C. Small amounts of urine voided 2 to 3 Small amounts of urine voided 2 to 3

times per hourtimes per hour D.D. Spasms and difficulty during Spasms and difficulty during

urinationurination

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Nursing ProcessNursing ProcessAlterations in Urinary FunctionAlterations in Urinary Function

Assessment: Nursing historyAssessment: Nursing history Physical Assessment-inspection, Physical Assessment-inspection,

percussion, palpationpercussion, palpation Assessment of Urine- color, clarity, odorAssessment of Urine- color, clarity, odor Urine testing & specimen collectionUrine testing & specimen collection Diagnostic tests: KUB, IVP, renal Diagnostic tests: KUB, IVP, renal

ultrasound, renal CT scanultrasound, renal CT scan Invasive-Cystoscopy, arteriogram, Invasive-Cystoscopy, arteriogram,

urodymanicsurodymanics

Urine Specimen Urine Specimen CollectionCollection

RandomRandom Clean-voided or midstreamClean-voided or midstream SterileSterile Timed specimens (24 hour Timed specimens (24 hour

collection)collection)

Urine TestingUrine Testing

UninalysisUninalysis

Specific GravitySpecific Gravity

Urine CultureUrine Culture

Nursing DiagnosisNursing Diagnosis IncontinenceIncontinence Self-Care deficitSelf-Care deficit Skin IntegritySkin Integrity Altered Urinary EliminationAltered Urinary Elimination PainPain Body Image DisturbanceBody Image Disturbance

ImplementationImplementation Promoting Normal MicturitionPromoting Normal Micturition MedicationsMedications Catheterization (Indwelling vs. straight)Catheterization (Indwelling vs. straight) Catheter Irrigations & InstillationsCatheter Irrigations & Instillations Routine Catheter Care/Perineal CareRoutine Catheter Care/Perineal Care Suprapubic CatheterizationSuprapubic Catheterization External Urinary Cathethers (Condom caths)External Urinary Cathethers (Condom caths) Female UrinalsFemale Urinals Maintaining Skin IntegrityMaintaining Skin Integrity Preventing InfectionPreventing Infection

Last Updated: April 1, 2005       Foley catheter

                                                                                                                                                         

Illustration copyright 2004 Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com An indwelling Foley catheter remains in place continuously. To keep the catheter from slipping out, there is a balloon on one end that is inflated with sterile water once that end is inside the bladder.

Medical Review: Adam Husney, MD - Family MedicineNancy Greenwald, MD - Physical Medicine and Rehabilitation

Last Updated: April 1, 2005