Stressors Affecting Elimination Urinary

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

PPP By Sharon Niggemeier RN, MSN

Anatomy & Physiology

Kidneys Ureters Bladder Urethra
http://www.youtube.com/watch?v=glu0dzK4dbU &feature=related

Anatomy & Physiology MATCHING

Lets test our ?PRIOR? Knowledge of the renal system.

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

Nephron Function
Functional unit of kidney 1 million per kidney 1200 ml blood pass through the kidney/min Wastes cannot be excreted as solids; must be excreted in solution Normal 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 Function
Blood filtered through glomerulus this filtrate moves into Bowmans capsules proceeds into proximal tubule where water /electrolytes/glucose & protein are reabsorbed Loop 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 pressure Structures 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 inches Urethra 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 Urine
Amount 1200 ml/day average Color Odor
See Next Slide

Turbidity
Specific gravity 1.010 1.025

Constituents

pH 4.6 8.0

Get a partner AND

Describe to them what normal urine smells like.
Ammonia? Concentrated urine d/t lack of adequate water intact OR Presence of bacteria in urine OR Standing urine (urea converts to ammonia when exposed to oxygen) 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. Sweet? Uncontrolled Diabetes Musty? Liver Disease

Factors That Affect Voiding

Food/fluid intake Life style + loss Medications Developmental factors
See Next Slide

???

Stress Activity/Muscle tone

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 patterns Recent changes Difficulties Artificial Orifices

Physical Assessment
Kidneys: R kidney located 12 rib L kidney lower Tenderness during palpation at costoverterbral angle? Bladder: Below symphysis pubis Supine position to examine Observe-roundness Palpate-tenderness, how high it distends Percussion- 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/dL Increased 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 Results

Serum creatinine - by product of muscle metabolismexcreted entirely by kidneys Normal = 0.5-1.2 mg/dL Increased levels signify renal impairment BUN: Creatinine ratio- 20:1 when both rise together indicates kidney failure or disease

Altered Urinary Functioning Terms to Know

Anuria Dysuria Enuresis Frequency Glycosuria Hematuria Hesitancy Frequency Incontinence Nocturia Oliguria Polyuria Pyuria Retention Urgency Proteinuria

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 Retention

Feeling of fullness Voiding small amounts
< 50 ml

Normal intake/inadequate output Distended bladder Discomfort Bladder Scan If > 300 ml should catheterize

Nursing Dx R/T Urinary Elimination

Impaired urinary elimination Urinary retention 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 Functional urinary incontinence Overflow urinary incontinence

Stress urinary incontinence

Reflex urinary incontinence Urge urinary incontinence Total urinary incontinence

Outcome Criteria
Patient will: Empty bladder completely at regular intervals Decrease episodes of incontinence Maintain regular urinary elimination pattern Develop adequate Intake/Output Have decreased dysuria

Nursing Interventions
Maintain voiding habits Promote fluid intake Strengthen muscle tone
Kegels 30-80/day

Stimulate urination
Auditory Tactile

Interventions: Toileting
Toilet Safety Concerns Commode Bedpan Female Hygiene Urinal Disposable Hat Fx pan

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 males Connects to drainage bag to collect urine Easy to apply and observe Comfortable Doesnt require intubation Prevents skin irritation from incontinence

Condom Catheter
Check every 2-4 hrs. Remove and replace every 24 hrs. Maintain free urinary drainage Never tape to skin Leave 1-2 inch space at tip of penis Secure snuggly but not too tight Follow manufacturer instructions

Urinary Catheterization
Used to: Keep bladder deflated during surgery Measure residual urine PVR (post void residual) should be < 50 ml Relieve retention Obtain 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 bladderleading to UTI (urinary tract infection) Performed using sterile technique...MD order needed Remains in place via inflated balloon

ALSO Suprapubic Catheter diverts urethra Urologic Stents- temporary in ureters permanent in urethra Ileal Conduit diversion of ureters to ileum and stoma; requires appliance

Medications Affecting Urinary Elimination

Antibiotics work against infection Bactrim, Levaquin, Cipro Urinary antispasmotics relieve spasms with UTI Ditropan, Pro-Banthine Diuretics.increase urinary output Lasix, Diuril Cholinergicsincrease muscle tone & function Used for urinary retention, neurogenic bladder Urecholine

Urinary Specimen Collection Refer to Lab Worksheet

Routine urinalysis Clean-catch/midstream urine Sterile specimen ( catheterization or from indwelling catheter) 24 hr. urine

Evaluating Urinary Elimination

Frequency Amount Ease/Difficulty

Color
Appearance Odor

Complete Intake and Output Exercise

Handout