Stressors Affecting EliminationUrinary

NUR101 Fall 2008Lecture # 22K. Burger, MSED, MSN, RN, CNE

PPP BySharon Niggemeier RN, MSN

AnatomyAnatomy & PhysiologyPhysiology

KidneysUretersBladderUrethrahttp://www.youtube.com/watch?v

=glu0dzK4dbU&feature=related

Anatomy & PhysiologyMATCHING

Let’s test our ?PRIOR? Knowledge of the renal system.

http://www.freenursetutor.com/urinary/flashcards-matching-urinary-system.html

Nephron FunctionFunctional unit of kidney1 million per kidney1200 ml blood pass through the

kidney/minWastes cannot be excreted as solids;

must be excreted in solutionNormal urine production = 1 ml / minute Kidneys must produce 30 ml/hr minimum

Critical Thinking

A client in hemorrhagic shock may proceed quickly into concomitant renal failure. Why?

Glomerular capillary blood pressure is the driving force of glomerular filtration. If blood pressure is not maintained, there is not enough osmotic gradient to sustain filtration.

Nephron FunctionBlood filtered through glomerulusthis filtrate moves into Bowman’s capsulesproceeds into proximal tubule where water

/electrolytes/glucose & protein are reabsorbedLoop of Henley – water and solutes such as Na

& Cl, are reabsorbed (urine becomes more concentrated)

distal convoluted tubules allows for water and NA reabsorbtion. Controlled reabsorption (by ADH antidiuretic hormone) regulates F/E balance…..collecting duct

Act of Micturition

Urine moves from the kidneys through ureters via peristaltic waves into bladder.

Bladder fills & detrusor muscles sense pressureStructures and functions for voluntary control of

voiding:

-External sphincter- restrain or interrupt act

-Conscious brain- starts act

-Intact spinal cord- needed or else message from the brain is not received.

Hmmm….

Why are UTIs more common in women than in men?

Urethra in women = 1.5 to 2.5 inchesUrethra in men = 6 – 8 inches

Alterations in Urinary Function

Incontinence- brain is not receiving impulse or loss of external sphincter control

Retention- distended bladder due to nerve impulses not perceived or muscles unable to function

Characteristics of UrineAmount

1200 ml/day average

Color

OdorSee Next Slide

pH 4.6 – 8.0

Turbidity

Specific gravity1.010 – 1.025

Constituents

Get a partner…AND

Describe to them what normal urine smells like.

Eau D’ Asparagus? Asparagus contains a sulfur compound called mercaptan. (It's also found in rotten eggs, onions, garlic, and in the secretions of skunks.) When your digestive tract breaks down this substance, by-products are released that cause the funny scent.

Ammonia? Concentrated urine d/t lack of adequate water intact ORPresence of bacteria in urine ORStanding urine (urea converts to ammonia when exposed to oxygen)

Sweet? Uncontrolled Diabetes Musty? Liver Disease

Factors That Affect Voiding

Food/fluid intake + loss

Developmental factorsSee Next Slide

StressActivity/Muscle

tone

Life styleMedications

???

Geriatric Considerations

Decreased ability of kidneys to concentrate urine and decreased bladder capacity = nocturia

Decreased muscle tone of bladder = increased frequency

Decreased bladder contractility & stasis= increased frequency of UTI

Changes in cognition and mobility (in some)= increased incontinence issues

Assessing Urinary Status

Usual patternsRecent changesDifficultiesArtificial Orifices

Physical AssessmentKidneys:R kidney located

12 ribL kidney lowerTenderness during

palpation at costoverterbral angle?

Bladder:Below symphysis

pubisSupine position to

examineObserve-roundnessPalpate-tenderness,

how high it distendsPercussion- full

bladder dull sound

Assessment: Lab Results

Urinalysis- WBC, RBC, protein, glucose, bacteria

= abnormal constituents BUN (blood urea nitrogen) end product of protein

metabolism… 10-20 mg/dLIncreased BUN (azotemia) signifies impaired kidney function… affected by diet (hi protein intake) and fluids (dehydration)

Decreased BUN signifies impaired liver function

Many drugs elevate BUN (antibiotics, lasix +++)

Assessment: Lab ResultsSerum creatinine - by product of muscle

metabolism…excreted entirely by kidneys… Normal = 0.5-1.2 mg/dLIncreased levels signify renal impairment

BUN: Creatinine ratio- 20:1… when both rise together indicates kidney failure or disease

Altered Urinary Functioning Terms to Know

AnuriaDysuriaEnuresisFrequencyGlycosuriaHematuriaHesitancyFrequency

IncontinenceNocturiaOliguriaPolyuriaPyuriaRetentionUrgencyProteinuria

NCLEX Question

Your client has a urinary tract infection.

Which of the following signs/symptoms

would you expect the client to exhibit?

a. Proteinuria

b. Dysuria

c. Oliguria

d. Polyuria

Assessing Urinary RetentionFeeling of fullnessVoiding small amounts

< 50 ml

Normal intake/inadequate output

Distended bladderDiscomfortBladder Scan

If > 300 ml should catheterize

Nursing Dx R/T Urinary Elimination

Impaired urinary elimination

Urinary retention

Functional urinary incontinence

Overflow urinary incontinence

Stress urinary incontinence

Reflex urinary incontinence

Urge urinary incontinence

Total urinary incontinence

Risk for infection r/t urinary retention and/or urinary catheterization

Risk for impaired skin integrity r/t urinary incontinence

Situational low self esteem r/t incontinence

Outcome CriteriaPatient will:Empty bladder completely at regular

intervalsDecrease episodes of incontinenceMaintain regular urinary elimination

patternDevelop adequate Intake/OutputHave decreased dysuria

Nursing Interventions

Maintain voiding habitsPromote fluid intake Strengthen muscle tone

Kegels 30-80/day Stimulate urination

AuditoryTactile

Interventions: Toileting

ToiletCommodeBedpanUrinalDisposable“ Hat” Fx pan

Safety Concerns

Female Hygiene

Interventions for Urinary Incontinence

Bladder training/ Habit training

External urinary device- Condom Catheter

Indwelling catheter-LAST resort

Condom Catheter (Texas Cath)Rubber condom placed on penis of

incontinent malesConnects to drainage bag to collect

urineEasy to apply and observeComfortableDoesn’t require intubationPrevents skin irritation from

incontinence

Condom CatheterCheck every 2-4 hrs.Remove and replace every 24 hrs.Maintain free urinary drainageNever tape to skinLeave 1-2 inch space at tip of penisSecure snuggly but not too tightFollow manufacturer instructions

Urinary Catheterization

Used to:Keep bladder deflated during surgeryMeasure residual urine

PVR (post void residual) should be < 50 mlRelieve retentionObtain sterile urine specimen

May use either:Straight catheter or indwelling catheter

Indwelling catheter Refer to Lab Worksheet

Catheter inserted into urinary meatus through urethra into bladder to drain urine

Last resort as it introduces microbes into bladder…leading to UTI (urinary tract infection)

Performed using sterile technique...MD order needed Remains in place via inflated balloon

ALSOSuprapubic Catheter – diverts urethraUrologic Stents- temporary in ureters permanent in urethraIleal Conduit – diversion of ureters to ileum and stoma; requires appliance

Medications Affecting Urinary Elimination

Antibiotics …work against infectionBactrim, Levaquin, Cipro

Urinary antispasmotics …relieve spasms with UTIDitropan, Pro-Banthine

Diuretics….increase urinary outputLasix, Diuril

Cholinergics…increase muscle tone & functionUsed for urinary retention, neurogenic bladderUrecholine

Urinary Specimen CollectionRefer to Lab Worksheet

Routine urinalysisClean-catch/midstream urineSterile specimen ( catheterization

or from indwelling catheter)24 hr. urine

Evaluating Urinary Elimination

FrequencyAmountEase/Difficulty

Color AppearanceOdor

Complete Intake and Output Exercise

Handout