urine elimination Concept of Elimination Elimination: removal of physiologic waste products from the body via excretion and secretion; two main pathways discussed here are urinary elimination (kidneys and intestines) and bowel elimination (fecal). Urinary elimination (kidneys and associated structures) handles:Solute waste from blood Excess liquid not needed for homeostasis Bowel elimination involves the processing and expulsion of unused portions of ingested solid material. Urinary Elimination: Overview Primary roles:Controls blood concentration and composition Rids body of excess fluid and electrolytes Normal urinary elimination supports:Maintenance of ion concentration necessary for neuronal and muscle function Bone strength Cellular regeneration Blood pressure homeostasis to ensure adequate circulation of oxygen and nutrients Physiology depends on proper function of both upper and lower urinary tracts. Anatomy of the Urinary Tract Upper urinary tract: kidneys and ureters Lower urinary tract: urinary bladder, urethra, pelvic floor Physiology of Urination (Micturition) Definition: the process of emptying the bladder Steps:Urine collects in the bladder Pressure stretches receptors in the bladder wall Stretch receptors transmit impulses to the voiding reflex center in the spinal cord If the environment is appropriate (time/place): the conscious brain relaxes the external urethral sphincter, and urination occurs If environment is not appropriate:The conscious mind delays urination The micturition reflex subsides until the bladder fills again Voluntary control requires intact nerves supplying the bladder, urethra, spinal cord and brain, and motor areas of the cerebrum Patterns of Voiding voiding patterns vary by individual General expectations:Everyone should void at least every 6 hours Most people void 6 ext{–}7 times per day A common reference range is 4 ext{ to }10 times per day Factors Affecting Urinary Elimination Fluid and food intake Muscle tone Psychosocial factors Pathologic conditions Surgical and diagnostic procedures Medications Alterations in Urination Alterations are common and can be age- or disease-related Understanding alterations helps in providing appropriate nursing interventions and high-quality, patient-centered care Alterations in Urination: Common Terminology Polyuria (diuresis): production of abnormally large amounts of urineCan cause excessive fluid loss, intense thirst, dehydration, weight loss Polydipsia: extreme thirst (often associated with polyuria) Anuria: absence of urine or < 100 ext{ mL/day} Oliguria: reduced urine productionDefined as < 400 ext{ mL/day} or < 30 ext{ mL/hour} May signal impending renal failure Urinary frequency Nocturia: voiding at night Urgency: sudden, strong desire to void Dysuria: painful or difficult voiding Urinary hesitancy Neurogenic bladder: does not perceive bladder fullness and/or cannot control urinary sphincters About half of all women will experience a urinary tract infection (UTI) at least once in life Women experience urinary incontinence more than men About 44 ext{ ext%} of adults aged 65+ ext{ years} experience urinary leakage Urinary retention is reported more by men and is related to treatment for enlarged prostate Lower urinary tract symptoms may be related to: constipation, irritable bowel syndrome, sexual activity, delayed/premature voiding Genetic Considerations and Nonmodifiable Risk Factors Disabilities (physical, cognitive, developmental) Family history of incontinence Genetic considerations: spina bifida, myelomeningocele Aging-associated factors: neurodegenerative diseases (Parkinson's, Alzheimer’s), general age-related changes in function Male-specific: enlarged prostate; Female-specific: weakened bladder/urethral sphincter support muscles Both: decreased bladder capacity Nursing Assessment Key components: observation and patient interview Focus areas:Voiding pattern Description of urine and any changes Urinary elimination problems Factors influencing urinary elimination Nursing Assessment: Physical Examination Abdominal assessment Examination of soft tissues of genitalia and perianal areas Urethral meatus examination Assess feces and urine Assess fluid volume status Urine tests:Urinalysis Urine culture Post-void residual urine Ultrasonic bladder scan Prostate-specific antigen (PSA) Urinary stress tests Radiologic exams:Intravenous pyelography (IVP) Retrograde pyelography Renal arteriography or angiography Nursing Assessment: Diagnostic Tests (Imaging and Others) Kidney, ureter, bladder (KUB) radiography Cystoscopy Noninvasive tests:Ultrasound Computed tomography (CT) Magnetic resonance imaging (MRI) Renal scan Kidney biopsy Blood levels of urea and creatinine Independent Interventions Interventions depend on the underlying cause and severity Examples:Increase fluid intake as appropriate Monitor intake and output (I&O) Catheter care Patient teaching Incontinence care Aseptic technique is essential Collaborative Therapies Referrals before or after discharge as needed:Wound and ostomy nurse Occupational therapist Home health nurse Medical supply company Include family members and caregivers Collaboration is particularly important for patients in long-term care or assisted living Collaborative Therapies: Pharmacologic Therapy Anticholinergic medications: reduce urinary frequency, treat incontinence Cholinergic medications: promote urination Antibiotics: treat urinary infections Urinary analgesics: treat pain Urinary antispasmodics: treat spasms Diuretics:Loop diuretics Thiazide diuretics Potassium-sparing diuretics Carbonic anhydrase inhibitors and osmotic diuretics Collaborative Therapies: Dialysis Indications: for patients with severely reduced or absent renal function Hemodialysis: blood flows through an external machine and returns to the body Peritoneal dialysis: dialysis solution is instilled into the abdominal cavity Dialysis must be performed at frequent intervals Lifespan Considerations Newborns Glomerular filtration rate (GFR) is lower than in adults Limitations in concentrating and diluting urine; monitor dehydration or overhydration Healthy newborns typically void within the first 24 hours By delivery, ensure void occurs within 48 hours Patterns of voiding: more frequent Urine may be cloudy in newborns; straw-colored in early infancy Toddlers and Preschoolers Most develop urinary control between ages 2 ext{ and }5 years Daytime control usually precedes nighttime control Reminders for hygiene: flushing, handwashing Instruction in wiping School-age Children Kidneys double in size between ages 5 and 10 Child typically voids 6 ext{ to }8 times per day Enuresis is common; diurnal enuresis (daytime) may be pathologic Pregnant Women Enlarging uterus increases urinary frequencysymptom often decreases during the second trimester and reappears in the third GFR rises by as much as 50 ext{%} beginning in the second trimester; remains high until birth Renal tubular reabsorption increases to compensate Glycosuria may occur due to kidneys’ inability to reabsorb all filtered glucose; may be normal or indicate gestational diabetes Postpartum: risk for overdistention, incomplete bladder emptying, residual urine UTIs risk increases postpartum Older Adults Renal function begins to decline with age Blood flow to kidneys decreases due to atrophy of supplying vessels Urine tends to be more dilute Nighttime diuresis occurs; more fluid, electrolytes excreted at night, potentially interrupting sleep Impaired excretion increases risk of drug overdose and adverse effects Decreased ability to concentrate urine increases dehydration risk Bladder becomes more fibrous with decreased capacity and increased residual urine Autonomic regulation of the bladder declines; pelvic floor muscles weaken Increased risk of hyponatremia Use of prescription diuretics for hypertension or cardiac conditions can worsen urine concentration and electrolyte regulation Knowt Play Call Kai