Download Fundamentals of Nursing II

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
 Let’s 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 Bowman’s 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
 Turbidity
 Odor
 Constituents
See Next Slide
 pH 4.6 – 8.0
 Specific gravity
1.010 – 1.025
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
metabolism…excreted 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
Functional urinary
incontinence
Overflow 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
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
 Doesn’t 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 bladder…leading
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
 Cholinergics…increase 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