ANATOMY AND PHYSIOLOGY

Kidneys and Ureters

 kidneys help maintain the composition and volume of body fluids
 the body's total blood volume passes through the kidneys once q30m for waste removal
 the nephron is the basic structural and functional unit of the kidneys (~1 million/kidney)
 nephrons remove the end products of metabolism (urea, creatinine, uric acid)
 a fold of membrane in the bladder closes the entrance to the ureters to prevent back flow
when pressure exists in the bladder
Bladder
 smooth muscle sac that serves as temporary reservoir for urine
 composed of three layers: the inner longitudinal, middle circular, and outer longitudinal.
These three layers collectively make up the detrusor muscle
 at the base of the bladder is the internal sphincter which guards the opening between the
bladder and the urethra
 the urinary bladder is innervated by the autonomic nervous system
 the sympathetic system carries inhibitory impulses to the bladder and motor impulses to
the internal sphincter
 the parasympathetic system caries motor impulses to the bladder and inhibitory impulses
to the internal sphincter
 when the pressure becomes sufficient to stimulate nerves an the bladder wall (stretch
receptors), the person feels a desire to empty the badder
Urethra
 functions to transport urine from bladder to the exterior of the body
 the external sphincter in under voluntary control
 note the differences between the male and female urethra
Act of Urination
 the process of emptying the bladder is known as urination, micturition, or voiding
 urination is a largely involuntary reflex, but its control can be learned
 desire to void coors when the badder fills to ~150 to 250ml in an adult
 the pressure in the bladder is many times greater during urination than the time the
bladder is filling
 when urination is initiated, the detrusor muscle contracts, the internal sphincter relaxes,
and urine enters the posterior urethra. the muscles of the perineum and external sphincter relax,
the muscle of the abdominal wall contracts slightly, the diaphragm lowers, and urination occurs
 urination is normally painless
 any involuntary loss of urine is referred to as urinary incontinence
 the voluntary control of urination develops as the higher nerve centers develop after
infancy, until that time, voiding is pursy a reflex action
 people whose bladders are no longer controlled by the brain because of injury or disease
also void by reflex only this is called autonomic bladder
Frequency of Urination
 dependent upon the amount of urine being produced
 most healthy people do not void during normal sleeping hours
 the first voided urine of the day is usually the most concentrated of the day
 because 1st void of the day is not fresh it may or may not be used for certain tests
 people who habitually urinate infrequently develop ore UTI's and kidney d/o's than those
who void q3-4h. this is believed to be due to the stagnation of urine in the bladder which serves
as a good medium for bacterial growth
 urinary retention occurs when urine is produced normally but is not excreted
completely from the bladder
 factors associated with urinary retention are medications, an enlarged prostate, or
vaginal prolapse
FACTORS AFFECTING URINATION

Developmental Considerations

 Infants are born without voluntary control or ability to concentrate urine

 urine is light in color and without odor
 @ ~ 6 weeks the infants nephrons are able to control reabsorption of fluids into the
tubules and effectively concentrate urine
 most children develop control between 2 and 5 years
 daytime control precedes nightime
 girls develop control earlier than boys (generally)
 older children and adults seldom wake to void d/t kidneys ability to concentrate urine and
produce less at night an decreased renal blood flow

Toilet Training:
 voluntary control of the urethral sphincters occurs between 18 and 24 months
 toilet training begins @ ~ age 2-3 years
 toilet training should not begin until chid can: hold urine for 2 hours, recognize feeling of
bladder fullness, communicate need to void and control urination until seated on toilet
 occasional daytime incontinence of urine in a child is usually not a cause for concern
Effects of Aging:
Physiologic changes that accompany normal ages may affect urination. These changes include:
 diminished ability of kidneys to concentrate urine may lead to nocturia
 decreased bladder muscle tone may reduce capacity for bladder to hold urine
 decreased contractility may lead to urinary retention and stasis, which increases
likelihood of UTI
 neuromuscular problems, degenerative joint problems, metal alterations, weakness-
interfere with voluntary control and ability to reach toilet in time
 Diuretics cause increased urine production, resulting in need for increased urination and
possibly urge incontinence
 sedatives and tranquilizers may diminish awareness of need to void
Food and Fluid Intake
 kidneys help body maintain careful balance of fluid intake an output, which should be
about equal
 when the body is dehydrated the kidneys reabsorb fluid and urine is more concentrated
and decreased in amount
 conversely, with fluid overload, kidneys produce a large volume of dilute urine
 caffeine containing beverages (cola, coffee, tea) have a diuretic effect
 alcohol inhibits the release of antidiuretic hormone
 foods and beverages with high sodium content cause sodium and water reabsorption and
retention, thereby decreasing urine formation
Psychological Variables

 individual, family, and sociocultural factors affect voids habits

 for some it is personal and private
 assistance can provoke embarrassment and anxiety
 some people that experience stress void in smaller more frequent amounts
 stress can interfere with the ability to relax they perineal muscles and external sphincter
Activity and Muscle Tone
 during prolonged periods of immobility, decreased bladder and sphincter tone can result
in poor urinary control and urinary stasis
 people with indwelling catheters can lose bladder tone because the bladder is not being
stretched
 other causes of decreased muscle tone include: childbearing, muscle atrophy due to
decreased estrogen as seen with menopause, and damage to muscles from trauma
Pathologic Conditions
 certain renal or urologic problems can affect quantity and quality of urine produced
 renal failure is a condition in which the kidneys fail to remove metabolic end products
from the blood and are unable to regulate fluid, electrolyte, and pH balance
 acute renal failure is a sudden decline in kidney function and may be caused by: severe
dehydration, anaphylactic shock, pyelonephritis, and ureteral obstruction
 chronic kidney disease is the end result of irreparable damage to the kidneys, developing
slowly over many years
 chronic renal failure is caused by conditions such as diabetes, hypertension, and
glomerulonephritis
 fever and diaphoresis result in fluid conservation by the kidneys. urine production is
decreased and urine is highly concentrated
 other pathologic conditions such as CHF, may lease to fluid retention an decreased urine
output
 high blood glucose levels, such as with diabetes mellitus, may lead to an increase in
urinary output 2/2 an osmotic diuretic effect
Medications

 meds have numerous effects on urine production and elimination

 nephrotoxic- having ability to cause kidney damage
 abuse of analgesics such as aspirin or ibuprofen (advil) can cause nephrotoxicity
 some antibiotics, such as gentamicin, can be nephrotoxic
 diuretics prevent the reabsorption of water and certain electrolytes in tubules
 cholinergic medications can stimulate the contraction of the detrusor muscle and produce
urination
 some analgesics and tranquilizers suppress the central nervous system , interfering with
urination by diminishing the effectiveness of the neural reflex
 Certain drugs cause changes in urine color as in the following:
1. anticoagulants may cause hematuria, leading to a pink or red color
2. diuretics can lighten urine to pale yellow
3. pyridium can caused orange-red color
4. antidepressant amitriptyline (elavil) or B complex vitamins can cause green or
blue green
5. Levodopa (l-dopa), an anitparkinson drug, and injectable iron compounds can
lead to dark brown or black urine
The Nursing Process for Urinary Elimination

Assessing
 Collection of data: voiding patterns, habits, difficulties, hx of current or past problems
 Physical examination of bladder, if indicated, and of urethral meatus; assessment of skin
integrity and hydration;examination of the urine
 Correlation of these findings with results of tests and examination
Nursing History:
 question pt on habits and current or past difficulties: patterns of elimination, changes in
elimination, aids to elimination, present or past voiding difficulties, presence of artificial orifices
(i.e. ileal conduit)
 with infant assess the number of wet diapers per day. newborns should have minimum 6
wet diapers/day
 with young children assess day and nighttime bladder control
 pts with urinary diversions may have specific care routines
 a urinary diversion involves the surgical creation of an alternate route for excretion of
urine
 when pt or caregiver reports prob, explore its duration, severity, and precipitating factors
 also note pt's perception of prob and set care procedures