NU101 Exam 3

maintains proper balance of fluids and electrolytes, minerals, and organic substances for homeostasis

• eliminates wastes and excess ions in form of urine

• blood filtration

• maintenance of fluid and electrolyte and acid-base balances

• production and release of rennin to promote angiotensin II activation and aldosterone production in adrenal gland

• promotes erythropoietin (hormone that stimulates RBC production and enzymes like rennin)

• convert vitamin D to more active form

• filters and excretes blood constituents not needed and retains those that are needed

• excretes waste products (urine)

• nephrons remove the end products of metabolism and regulate fluid balance

• urine from nephrons empties into kidneys

• urine is then transported to the bladder via the ureters

function of the kidney

enzyme that governs the blood pressure and kidney function

rennin

the basic structural and functional unit of the kidneys

nephrons

urea, creatinine, and uric acid from blood plasma

end products of metabolism

• acts as a reservoir for urine and is the organ of excretion

• men: bladder lies in front of the rectum and above the prostate gland

• women: bladder lies in front of the uterus and vagina

• it’s a smooth muscle sac innervated by ANS

• composed of 3 layers of muscle tissue called detrusor muscle

• sphincter guards opening between urinary bladder and urethra

• urethra conveys urine from bladder to exterior of body

function of the bladder

• carries urine out of the body through the urinary meatus

• women are more prone to UTIs because of their short urethra and the proximity of the urinary meatus to the vagina

function of the urethra

• the process of emptying bladder

• nerve centers for urination is in the brain and spinal cord

• involuntary reflex but control can be learned

• voluntary control develops in higher nerve centers after infancy

• people have an autonomic bladder if they can no longer control bladders with the brain because of injury or disease

• urge to void is usually when the bladder fills at 150-250 mL in an adult

• when it’s time to urinate, the:

  • detrusor muscle contracts, internal sphincter relaxes, and urine enters posterior urethra

  • muscles of perineum and external sphincter relax

  • muscle of abdominal wall contracts slightly, diaphragm lowers, and urination occurs

act of urination (micturition or voiding)

factors

• diminished ability of kidneys to concentrate urine can result in nocturia (urination during the night)

• decreased bladder muscle tone may reduce the capacity of bladder to hold urine

  • results in increased frequency of urination

• decreased bladder contractility may lead to urine retention and stasis

  • results in increased likelihood of UTI

• neuromuscular problems, degenerative joints, alteration in thought processes, and weakness may interfere with voluntary control and ability to reach toilet in time

• those who view themselves as old, powerless, and neglected may cease to value voluntary control over urination and simply find toileting too much bother no matter what the setting is. incontinence may be the result

effects of aging affecting urination

factors

• when body is dehydrated, the kidneys reabsorb fluid

  • urine produced is more concentrated and is decreased in amount

  • with fluid overload kidneys excrete a large quantity of dilute urine

• alcohol produces diuretic effect inhibiting release of antidiuretic hormone, thus increasing urine production

• foods high in water may increase urine production

• foods and beverages high in sodium cause sodium and water reabsorption and retention

  • results in decreased urine formation

food and fluid intake affecting urination

factors

• some who experience stress void smaller amounts of urine at more frequent intervals

• stress can interfere with the ability to relax the perineal muscles and external urethral sphincter

  • person may feel the urge to void, but emptying the bladder becomes difficult

psychological variables affecting urination

factors

• regular exercise increases metabolism and optimal urine production and elimination

• prolonged periods of immobility decreases bladder and sphincter tone

  • results in poor urinary control and urinary stasis

  • people with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by bladder filling with urine

• other causes of decreased muscle tone

  • childbearing

  • muscle atrophy due to decreased estrogen levels as seen with menopause

  • damage to muscles from trauma

activity and muscle tone affecting urination

factors

• renal or urologic problems can affect quantity and quality of urine produced

• diseases associated with renal problems:

  • congenital urinary tract abnormalities, UTI, urinary calculi (kidney stones), hypertension, diabetes mellitus, gout, and certain connective tissue disorders

• renal failure: condition in which kidneys fail to remove metabolic end products from blood and are unable to regulate fluid, electrolyte, and pH balance

• acute kidney injury (AKI): sudden decline in kidney function

  • possible causes: severe dehydration, anaphylactic shock, sepsis, and ureteral obstruction

• chronic kidney disease (CKD): slow loss of kidney function over months or years as result of irreparable damage to kidneys

  • possible causes: diabetes, hypertension, glomerulonephritis (inflammation of the glomerulus)

  • progression of CKD can lead to renal failure

• diseases that reduce physical activity or lead to generalized weakness:

  • arthritis, parkinson’s disease, degenerative joint disease

  • can interfere with toileting

• cognitive deficits and certain psychiatric problems can interfere with a person’s ability or desire to control urination volunteraily

• fever and diaphoresis result in body fluid conservation by kidneys

  • results in:

    • decreased urine production

    • urine is highly concentrated

• heart failure may lead to fluid retention and decreased urine output

• high blood glucose levels may lead to increased urine output secondary to an osmotic diuretic effect

pathologic conditions affecting urination

a condition in which the kidneys fail to remove metabolic end products from blood and are unable to regulate fluid, electrolyte, and pH balance

renal failure

sudden decline in kidney function

• possible causes: severe dehydration, anaphylactic shock, sepsis, and ureteral obstruction

acute kidney injury (AKI)

slow loss of kidney function over months or years as the result of irreparable damage to kidneys

• possible causes: diabetes, hypertension, glomerulonephritis

chronic kidney disease (CKD)

inflammation of the glomerulus

glomerulonephritis

heart failure may lead to fluid retention and ____ (increased/decreased) urine output

decreased

fever and diaphoresis result in body fluid conservation by the kidneys, which leads to ____ (increased/decreased) urine production

decreased

high blood glucose levels may lead to ___ (increased/decreased) urine output secondary to an osmotic diuretic effect

increased

factors

• may interfere with bladder function

  • i.e. diuretics: prevent reabsorption of water and certain electrolytes in tubules

    • increased urination and possibly urge incontinence

• sedatives and analgesics may diminish awareness of need to void by suppressing CNS

• greatest concern is of nephrotoxic drugs = capable of causing kidney damage

  • abuse of analgesics (aspirin and ibuprofen) can cause nephrotoxicity

  • some antibiotics like gentamicin can cause nephrotoxicity

• cholinergic meds stimulate contraction of detrusor muscles and produce urination

• drugs that cause urine to change color: anticoagulants, diuretics, pyridium, B-Complex vitamins and Elavil, levodopa

medications affecting urination

the involuntary loss of urine that occurs soon after feeling the urgent need to void

urge incontinence

what color urine do anticoagulants cause?

pink or red (hematuria)

blood in urine

hematuria

what color urine do diuretics cause?

pale yellow

what color urine does pyridium cause?

orange to orange-red

what color urine do b-complex vitamins and elavil cause?

green or blue-green

what color urine does levodopa cause?

brown or black

nursing process

• collection of data about the patient’s voiding patterns, habits, and difficulties. history of current or past urinary problems

• assessment of blader, skin integrity, hydration, and examination of urine

• physical assessment

assessment for urinary elimination

24 hour urine output is less than 50 mL, failure of the kidneys to produce urine

anuria

painful or difficult urination

dysuria

increased incidence of voiding

frequency

presence of glucose in urine

glycosuria

awakening at night to urinate

nocturia

24 hour urine output less than 400 mL, production of abnormally small amounts of urine

oliguria

excessive output of urine (diuresis), dilute urine

polyuria

protein in urine

proteinuria

pus in urine typically from bacterial infection

pyuria

strong desire to void

urgency

involuntary loss of urine

urinary incontinence

assessment

kidneys

• palpation usually performed with detailed assessment

• requires deep palpation and is generally assessed by advanced HCP

bladder

• indicated when the patient experiences difficulty voiding or other problems in elimination

• can’t be palpated or percussed when empty

• before palpating bladder, always ask when the patient last voided

• observe lower abdominal wall, noting any swelling and palpate for tenderness

• if there is distension, note smoothness and roundness of bladder

• use bedside scanner to assess fullness of bladder

  • determines bladder urine volume

  • most accurate in supine position

urethral orifice

• inspect for signs of inflammation, discharge, or foul odor

skin integrity and hydratation

• assess skin for color, texture, and turgor

• assess skin in perineal area

  • problems with incontinence may result in abrasion of epidermis = severe excoriation

urine

• assess for color, odor, clarity, and presence of any sediment

• for some patients, monitor the pH and specific gravity of urine

• check urine for abnormal constituents like: protein, blood, glucose, ketone bodies, and bacteria

physical assessment for urinary elimination

measurement of density of urine compared to density of water

specific gravity of urine

1.010-1.025

specific gravity of urine values

normal findings

• a freshly voided specimen is pale yellow, straw-colored, or amber, depending on its concentration

special considerations

• urine is darker than normal when it is concentrated. urine is lighter than normal when it is diluted

• certain drugs, such as cascara, l-dopa, and sulfonamides, alter the color of urine

• some foods can alter the color; for example, beets can cause urine to appear red

color of urine

normal findings

• normal urine smell is aromatic. as urine stands, it often develops an ammonia odor because of bacterial action

special considerations

• some foods cause urine to have a characteristic odor; for example, asparagus causes urine to have a strong, musty odor

• urine high in glucose content has a sweet odor

• urine that is heavily infected has a fetid odor

odor of urine

normal findings

• the normal pH is 5-6, which a range of 4.5-8. urine becomes alkaline on standing when carbon dioxide diffuses into the air. urine alkalinity or acidity may be promoted through diet to inhibit bacterial growth or urinary stone development or to facilitate the therapeutic activity of certain medications

special considerations

• a high-protein diet causes urine to become excessively acidic

• certain foods tend to produce alkaline urine, such as citrus fruits, dairy products, and vegetables, especially legumes

• certain foods such as meats tend to produce acidic urine

• certain drugs influence the acidity or alkalinity of urine; for example, ammonium chloride produces acidic urine, and potassium citrate and sodium bicarbonate produces alkaline urine

pH of urine

normal findings

• this is a measure of the density of the chemicals and particles in the urine and is a measure of the ability of the kidneys to concentrate urine

special considerations

• concentrated urine will have a higher than normal specific gravity; diluted urine will have a lower than normal specific gravity

• in the absence of kidney disease, a high specific gravity usually indicates dehydration and a low specific gravity indicates overhydration

specific gravity of urine

normal findings

• organic constituents of urine include urea, uric acid, creatinine, hippuric acid, indican, urene pigments, and undetermined nitrogen

• inorganic constituents are ammonia, sodium, chloride, traces of iron, phosphorus, sulfur, potassium, and calcium

special considerations

• abnormal constituents of urine include blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile

constituents of urine

• measure patient fluid intake and output

• aids in identifying potential alterations in fluid balance

• measurement of fluid intake and output can be delegated to unlicensed personnel

• minimum kidney function = 30 mL urine/hour

• output < 30 mL/day may indicate decreased blood flow to kidney

• should almost equal intake (within a 2-3 day range)

measure urinary output

30 mL urine/hour

what is the minimum kidney function amount?

collecting urine specimens

• sterile urine not required

• have patient void into clean bedpan or urinal and take care to avoid contamination with feces

• if woman is menstruating, note in lab slip because RBC may appear in the urine

• use aseptic technique to pour urine in appropriate container and label it with the patient’s name/date/and time of collection

• if specimen is not processed or refrigerated within 1 hour of collection, changes in appearance and composition or urine may occur

routine urinalysis

collecting urine specimens

• clean-catch specimen collected during midstream

• patient avoids and discards small amount of urine into toilet, etc

• uses container and continues to void into container

• first small amount of urine flushes away any organisms near meatus and prevents it from entering specimen for inaccurate readings

clean-catch or midstream specimen

collecting urine specimens

• may be obtained by catheterizing the patient’s bladder or taking specimen from an indwelling catheter already in place

• patient with indwelling catheter: specimen must be collected from the catheter itself using a special port for the specimen

  • specimen in collecting drainage bag may be fresh urine and can result in inaccurate readings

sterile specimen

collecting urine specimens

• collection of specimens at specific time for 24 hours

24 hour urine specimen

7-20 mg/dl

BUN values

90-120 mL/min

GFR values

0.5-1.1 mg/dl

creatinine values in women

0.6-1.2 mg/dl

creatinine values in men

urinary functioning as the problem

• specifically addresses problems in urinary functioning. includes:

  • incontinence, pattern alteration, urinary retention

urinary functioning as the etiology

• difficulty with urination or changes in normal voiding patterns may affect other areas of human functioning

• examples of nursing diagnoses related to urinary problems:

  • impaired skin integrity

  • disturbed body image

  • toileting self-care deficit

  • risk for infection

  • anxiety