Week 8 Notes

Chapter 46: Urinary Elimination

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Scientific Knowledge Base

  • Components of the Urinary System:

    • Kidneys

    • Ureters

    • Bladder

    • Urethra

Functions of the Kidney

  • Roles of the Kidney in the Body:

    • Elimination of Body Wastes: Removes waste products from the metabolism of body cells.

    • Regulation of Fluid and Electrolyte Balance: Maintains homeostasis by regulating body fluids and essential electrolytes.

    • Erythropoietin Production: Stimulates blood cell production and maturation of bone marrow.

    • Blood Pressure Control:

    • Via the renin-angiotensin system:

      • Renin Release: Juxtaglomerular cells in kidneys secrete renin.

      • Conversion: Renin converts angiotensinogen to angiotensin I in kidneys.

      • Angiotensin II Formation: Angiotensin I is converted to angiotensin II in the lungs.

      • Effects of Angiotensin II: Causes vasoconstriction and stimulates the adrenal cortex to release aldosterone, which causes water retention.

    • Vitamin D Activation: Kidneys convert vitamin D into calcitriol, enhancing calcium absorption from intestines into blood.

    • Consequences of Kidney Impairment: Can lead to anemia, hypertension (HT), and electrolyte imbalances.

Act of Urination (Voiding)

  • Mechanism of Voiding:

    • Bladder contraction + relaxation of urethral sphincters and pelvic floor muscles.

    • Micturition Centers in Spinal Cord:

    • Thoracic Center: Inhibits bladder contractions as the bladder fills.

    • Message Trigger: When bladder fills to 400-600 mL, the CNS sends signals to switch from sympathetic to parasympathetic stimulation from sacral micturition center.

    • Process: The external sphincter relaxes, leading to empting of the bladder.

Factors Influencing Urination

  • Growth and Development:

    • Children gain voluntary control over voiding by 18 to 24 months.

    • Older adults experience decreased bladder capacity, irritability, and contractions; may also see an increased risk of incontinence due to chronic illnesses and mobility issues.

  • Sociocultural Factors: Norms related to privacy and availability of facilities affect urination patterns.

  • Psychological Factors: Anxiety and stress can impact the ability to urinate consistently.

  • Personal Habits: Need for privacy and adequate time for voiding can influence urination behavior.

  • Fluid Intake: Increased fluid intake results in higher urine production; alcohol reduces ADH release, causing increased urine volume; caffeine causes urgency and incontinence.

  • Pathological Conditions & Medications:

    • Conditions such as diabetes mellitus, multiple sclerosis, spinal injuries can influence urinary control.

    • Trauma or surgical procedures can obstruct urine flow.

    • Anesthetic agents and sedatives may reduce bladder contractility.

    • Diuretics increase urinary output by preventing water and electrolyte reabsorption.

    • Certain medications change urine color (e.g., phenazopyridine causes orange urine, riboflavin makes it yellow).

Common Urinary Elimination Problems

  • Urinary Retention:

    • Definition: Accumulation of urine due to impaired bladder emptying; pressure exceeds sphincter capability, leading to dribbling.

    • Symptoms may include no output, frequency, urgency, or small volume voiding.

    • Postvoid Residual (PVR): Amount of urine remaining in the bladder after voiding, measured via ultrasound or catheterization.

    • Causes:: Infection, irritability, obstruction, impaired contractility, and dysfunction may lead to inability to void.

  • Urinary Tract Infection (UTI):

    • Typically from Escherichia coli.

    • Symptoms of Lower UTI: Burning during urination (dysuria), urgency, frequency, incontinence, abdominal tenderness, foul-smelling cloudy urine.

    • Symptoms of Upper UTI (Pyelonephritis): Fever, chills, sweating, flank pain.

    • Special Note: Catheter-associated UTIs (CAUTIs) lead to more hospitalizations and increased healthcare costs.

  • Urinary Incontinence:

    • Types of UI:

    • Urgency UI: Involuntary leakage associated with sense of urgency.

    • Stress UI: Leakage during exertion (sneezing, coughing).

    • Mixed UI: Presence of both stress and urgency symptoms.

    • Overflow UI: Leakage caused by an overfull bladder.

    • Functional UI: Impairments in mobility, cognition or access to toilet facilities lead to incontinence.

Urinary Diversion and Catheterization

  • Urinary Diversion: Redirecting urine to an external source, e.g.,

    • Continent Urinary Reservoir: Allows voluntary control over voiding.

    • Ureterostomy/Ileal Conduit: Urine bypasses the bladder and is redirected outside the body.

  • Nursing Knowledge Base:

    • Understanding the principles of infection control and hygiene, especially in urinary care.

Assessment

  • Patient Assessment:

    • Through the patient’s eyes: Understanding their urinary problems and treatment expectations.

    • Assess self-care abilities and cultural considerations.

    • Collect nursing history focusing on urination patterns and alterations.

  • Physical Assessment:

    • Examine the kidneys, bladder, external genitalia, urethral meatus, and perineal skin for signs of infection or functional issues.

Laboratory and Diagnostic Testing

  • Requirements Before Testing:

    • Signed consent, allergy assessment, bowel-cleansing as required, adherence to dietary restrictions.

  • Post-Test Responsibilities:

    • Assess I&O, voiding, and encourage fluid intake.

Urine Testing and Analysis

  • Types of Urine Samples:

    1. Random urinalysis with a clean cup.

    2. Midstream urine for culture & sensitivity with a sterile cup.

    3. Timed specimens measuring substances excreted over time.

  • Normal Urinalysis Results:

    • pH: 4.6 to 8.0

    • Protein: Up to 8 mg/100 mL (elevated indicates kidney damage).

    • Glucose and Ketones: Should not be present.

    • Blood: Indicative of glomeruli damage or trauma to the urinary tract.

    • Specific Gravity: 1.0053 to 1.030 (indicates hydration status).

    • Crystals: Presence may indicate risk for renal calculi.

Nursing Diagnosis

  • Common diagnoses related to urinary elimination include:

    • Functional urinary incontinence

    • Stress urinary incontinence

    • Urge urinary incontinence

    • Risk for infection

    • Toileting self-care deficit

    • Impaired skin integrity

    • Impaired urinary elimination

    • Urinary retention

Planning

  • Goals and Outcomes:

    • Set realistic, individualized goals with the patient.

    • Team collaboration to establish priorities based on immediate physical needs and readiness for self-care activities.

Implementation

  • Health Promotion Strategies:

    • Education on maintaining normal voiding and fluid intake habits.

    • Advocating for adequate hydration (6-8 glasses of water a day).

    • Recommendations to avoid irritants such as caffeine.

    • Scheduled toileting habits to ensure regular voiding.

  • Specific Techniques for Bladder Patients:

    • Manual pressure (Credé’s maneuver) to assist in emptying the bladder.

    • Catheterization methods for patients needing assistance with retention.

Catheterization Techniques

  • Types of Catheters:

    • Single, Double, Triple Lumen: Varieties serve different purposes based on clinical needs.

    • Indwelling Catheters: Remain in place for ongoing management.

    • Indications include post-surgical monitoring and neurological conditions.

  • Care for Catheter Systems:

    • Ensure proper hygiene to reduce CAUTI risk.

    • Monitor fluid drainage and maintain below bladder level.

Alternatives to Catheterization

  • Suprapubic Catheterization: Inserted through the abdominal wall for urinary obstruction cases.

  • External Catheters: Noninvasive methods for urine collection in male patients.

Medications Impacting Urination

  • Antimuscarinics: Treat urgency and frequency (e.g., darifenacin). Adverse effects include dry mouth and constipation.

  • Bethanechol: Used for urinary retention.

  • Tamsulosin and Finasteride: Help manage prostate conditions affecting urine flow.

Continuing and Restorative Care

  • Pelvic Floor Training and Bladder Retraining: Exercises to improve muscle control and manage urinary urgency.

  • Scheduled Toileting: Encouraging fixed intervals to enhance bladder habits.

Case Study: Mrs. Vallero

  • Background: 65-year-old with heart failure, diabetes, and urinary retention post-indwelling catheter.

    • Interventions: Scheduled toileting, fluid intake, and pressure techniques (Credé’s method) to manage urinary retention.

    • Goals: Achieving normal micturition and reducing dribbling episodes within a month.

Evaluation

  • Assess outcomes against expected goals related to urinary patterns and comfort post-interventions.

Safety Guidelines

  • Follow aseptic technique, particularly during catheterizations.

  • Remain vigilant for latex allergies among patients.

Summary

  • Comprehensive understanding of urinary elimination is essential for patient care, including anatomy, common issues, interventions, and diagnostics.

    • Continuous evaluation of patient responses to medical and nursing interventions will ensure effective urinary health management.