Download Urinary System Organs Renal Nephron

Chapter 45
Urinary Elimination
Scientific Knowledge Base:
Organs of Urinary Elimination
Kidneys
Ureters
Remove waste from the
blood to form urine
Transport urine from the
kidneys to the bladder
Bladder
Urethra
Reservoir for urine until the
urge to urinate develops
Urine travels from the
bladder and exits through
the urethral meatus.
Urinary System
Urinary System Organs
Renal Nephron
Additional Kidney Functions
 Production of erythropoietin is essential to
maintaining a normal red blood cell (RBC) volume.
 Erythropoietin stimulates bone marrow to produce RBCs and
prolongs the life of mature RBCs.
 Production of renin, prostaglandin E2, and
prostacyclin affects blood pressure.
 Renin starts a chain of events that cause water retention,
thereby increasing blood volume.
 Prostaglandin E2 and prostacyclin aid vasodilation.
 Kidneys affect calcium and phosphate regulation
Act of Urination
 Brain structures influence bladder function.
 Voiding: Bladder contraction + Urethral sphincter and
pelvic floor muscle relaxation
1. Stretching of bladder wall signals the micturition center
in the sacral spinal cord.
2. Impulses from the micturition center in the brain
respond to or ignore this urge, thus making urination
under voluntary control.
3. When a person is ready to void, the external sphincter
relaxes, the micturition reflex stimulates the detrusor
muscle to contract, and the bladder empties.
Factors Influencing Urination
 Disease conditions
 Medications and medical procedures
 Socioeconomic factors (need for privacy)
 Psychological factors (anxiety, stress, privacy)
 Fluid balance
 Nocturia, polyuria, oliguria, anuria
 Diuresis
 Fever
Disease Conditions Affecting Urination
 Prerenal, renal, postrenal classification
 Conditions of the lower urinary tract
 Diabetes mellitus and neuromuscular diseases such as
multiple sclerosis
 Benign prostatic hyperplasia
 Cognitive impairments (e.g., Alzheimer’s)
 Diseases that slow or hinder physical activity
 Conditions that make it difficult to reach and use toilet
facilities
 End-stage renal disease, uremic syndrome
Medical Interventions Affecting
Urination
 Surgical procedures
 Restriction of fluid intake lowers urine output.
 Stress causes fluid retention.
 Medications
 Some cause urinary retention and/or overflow incontinence.
 Some cause urgency and incontinence.
 Some change the color of urine.
 Diagnostic examinations
 Restriction of fluid intake lowers urine output.
 Direct visualization causes localized trauma and edema;
patients may have difficulty voiding.
Dialysis
 Renal Replacement
 Two methods
 Peritoneal
 Hemodialysis
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Indications for Dialysis
Renal failure that can no longer be controlled by
conservative management (Conservative management
would include dietary modifications and the administration
of medications to correct electrolyte abnormalities.)
Worsening of uremic syndrome associated with ESRD,
which would include nausea, vomiting, neurological
changes, and pericarditis)
Severe electrolyte and/or fluid abnormalities that cannot be
controlled by simpler measures (These abnormalities would
include hyperkalemia and pulmonary edema.) by simpler
measures
Case Study
 Mrs. Vallero is a 65-year-old woman who has been in
the hospital for 4 days with problems related to heart
failure, fluid retention, and diabetes. She has a
history of urinary retention secondary to neuropathy
caused by her diabetes.
 Mrs. Vallero’s indwelling urinary catheter was
removed 2 days ago and subsequently was replaced
yesterday at 6 AM because of her inability to urinate
more than 100 mL at a time, being incontinent of
small amounts of urine, complaints of urinary
urgency, and lower abdominal pain.
Case Study (cont’d)
 Sandy notes that the urinary catheter was removed at
7 AM this morning, and the patient has no recorded
urine output for the day. Mrs. Vallero verifies that she
has only “dribbled” urine. While making rounds,
Sandy talks with Mrs. Vallero, who says she is
worried because “I thought this was all under control.”
 The health care provider is notified, and an order is
obtained for an intermittent catheterization. The
registered nurse on the day shift catheterizes Mrs.
Vallero at 3 PM with a return of 600 mL of pale, clear
yellow urine.
Case Study (cont’d)
 As Sandy prepares to assess Mrs. Vallero again, she
remembers that urinary problems are common in
patients who have diabetes and in older adults. Age
alone does not cause incontinence. She recalls that
patients with urinary retention sometimes leak or
“dribble” urine and are then misdiagnosed as
incontinent.
 She knows that patients generally void at least every
6 to 8 hours, and that Mrs. Vallero’s recent
catheterization, her decreased mobility, and her
history of diabetes make her more prone to urinary
retention, incontinence of small amounts of urine, and
urinary tract infection (UTI).
Alterations in Urinary Elimination
Urinary retention
Urinary tract infection
An accumulation of urine
due to the inability of the
bladder to empty
Results from catheterization
or procedure
Urinary incontinence
Urinary diversion
Involuntary leakage of urine
Diversion of urine to
external source
Types of Urinary Diversions
Urinary Diversion
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Nursing Knowledge Base &
Assessment
Infection control and hygiene
Growth and development
Muscle tone
Psychosocial considerations
Cultural considerations
Urine Collection in Children
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Specimen collection from infants and children
is often difficult.
Adolescents and school-aged children usually
are able to cooperate.
Preschool children and toddlers have
difficulty voiding on request.
Physical Assessment
 Gather nursing history for the patient’s urination pattern
and symptoms, and factors affecting urination.
 Conduct physical assessment of the patient’s body
systems potentially affected by urinary change.
 Assess characteristics of urine.
 Assess the patient’s perception of urinary problems as it
affects self-concept and sexuality.
 Gather relevant laboratory and diagnostic test data.
Physical Assessment
Skin and mucosal
membranes
Kidneys
Assess hydration.
Flank pain may occur with
infection or inflammation.
Bladder
Urethral meatus
Distended bladder rises
above symphysis pubis.
Observe for discharge,
inflammation, and lesions.
Assessment of Urine
 Intake and output
 Characteristics of urine
 Color
 Pale-straw to amber color
 Clarity
 Transparent unless pathology is present
 Odor
 Ammonia in nature
 Urine testing
 Specimen collection
Urine Tests and Diagnostic
Examinations
Urinalysis
Specific gravity
Culture
Noninvasive procedures
Invasive procedures
Case Study (cont’d)
 Sandy knows that she will need to assess whether
Mrs. Vallero feels the urge to urinate. She determines
that no one has taken Mrs. Vallero to the bathroom
recently. Sandy also needs to find out more about her
patient’s urination patterns at home because Mrs.
Vallero has verbalized anxiety about her present
voiding patterns.
 Previous clinical experience has taught Sandy that
palpation of the abdomen over a distended bladder
causes some discomfort, and that the patient often
experiences an urge to urinate. Mrs. Vallero grimaces
when her abdomen is palpated and says she has a
little pain.
Restorative Care
 Strengthening pelvic floor muscles
 Bladder retraining
 Habit training
 Self-catheterization
 Maintenance of skin integrity
 Promotion of comfort
Evaluation
 Evaluate whether the patient has met outcomes and
goals.
 Check how the patient reports progress made.
 Help the patient redefine goals if necessary.
 Revise nursing interventions as indicated.
Case Study (cont’d)
 Sandy talks with Mrs. Vallero the next evening. The
patient’s care plan incorporates scheduled voiding,
oral fluids, and use of Credé’s method of manual
compression during voiding. She palpates
Mrs.Vallero’s bladder and then assists her to the
toilet.
 After making sure she is comfortable and leaving the
call light in place, Sandy instructs her to use Credé’s
method of manual compression. She returns to
measure Mrs. Vallero’s urinary output and evaluates
for bladder residual using an ultrasound bladder
scan.
Case Study (cont’d)
 Ask Mrs. Vallero about her urge to void, sensation of
bladder fullness, and dribbling episodes.
 Have Mrs. Vallero keep a log of her pattern of
elimination, including urine output volumes with each
voiding, during the 1-month period.
 Ask Mrs. Vallero if she continues to have lower
abdominal pain.
Case Study (cont’d)
 Mrs. Vallero is concerned about regaining her urinary
function. Sandy develops the following outcome for
her: At the end of the teaching session, Mrs. Vallero
will be able to describe approaches to promote
normal urinary elimination habits.
 What teaching strategies would you put into the plan?
 What evaluation strategies would you use?