NURS 1067 Week 11

1. Impaired Urinary Elimination

  • Definition: A general diagnosis that indicates issues in normal urinary functions.

  • Purpose: Helps nurses support clients until a more specific medical or nursing diagnosis can be identified (e.g., stress incontinence, urge incontinence).

  • Approach: More precise diagnoses are developed as additional data on the client is collected.

2. Nocturia

  • Definition: A lower urinary tract symptom characterized by the need to wake up at night to urinate. Includes the number of times urine is passed during the main sleep period.

  • Differentiation: Distinction between:

    • Nocturia: waking up specifically to void.

    • Not nocturia: waking for reasons unrelated to voiding.

  • Prevalence: Increases with age and is associated with various conditions such as:

    • Overactive bladder

    • Prostate enlargement in men

    • Congestive heart failure

    • Sleep apnea

3. Urinary Incontinence

  • Definition: “Uncontrolled loss of urine that is of sufficient magnitude to be a problem.” (Lewis et. al., 2014, p.1315)

  • Demographics: Can affect individuals across the lifespan, though it is more common among older adults. It is not a natural progression of aging.

  • Gender Differences: Higher prevalence among women compared to men, particularly in younger adults.

  • Impact: Can significantly affect quality of life and may lead to serious health consequences.

  • Causes: Urinary incontinence is a symptom that stems from various conditions.

Types of Urinary Incontinence

  • Functional Incontinence: Untimely urination due to physical or cognitive disabilities.

  • Urgency Incontinence: Involuntary leakage accompanied by urgency.

  • Stress Incontinence: Involuntary leakage when exerting pressure (e.g., sneezing, coughing).

  • Mixed Incontinence: Combination of stress and urge incontinence.

  • Overflow Incontinence: Associated with chronic retention where unexpected leakage occurs due to an overfilled bladder.

  • Transient Incontinence: Temporary leakage due to passing conditions (e.g., infection, medication).

  • Total Incontinence: Continuous loss of urine that is unpredictable.

4. Urinary Retention

  • Definition: “Inability to empty the bladder despite micturition or the accumulation of urine in the bladder due to an inability to urinate.” (Lewis et. al., 2014, p.1315)

    • Chronic: Incomplete bladder emptying despite efforts to urinate.

    • Acute: Total inability to urinate, requiring urgent medical attention.

Causes of Urinary Retention

  • Deficient Detrusor Muscle Strength: Not contracting sufficiently to empty the bladder, often due to neurological diseases, over-distension, alcoholism, or medications (e.g., anticholinergics).

  • Bladder Outlet Obstruction: Physical obstruction preventing bladder emptying.

  • Additional Causes: Surgical or childbirth trauma, fecal impaction.

Obstructive Uropathies Related to Urinary Retention

  • Pelvis: Calculi, tumor.

  • Ureter (intrinsic): Calculi, tumor, clot, inflammation, foreign body.

  • Ureter (extrinsic): Pregnancy, tumors such as those in the cervix, ureteral strictures.

  • Bladder: Calculi, tumors, functional issues (e.g., neurogenic), narrowing of the ureterovesical junction, prostate issues (hyperplasia, carcinoma), urethral stricture.

Clinical Manifestations of Urinary Retention

  • Symptoms include pressure, discomfort, tenderness in the suprapubic area, restlessness, diaphoresis, overflow incontinence, voiding small amounts frequently with no comfort post-void, and post-void residual greater than 150 ml.

Measuring Post-Voiding Residual

  • Tool: BladderScan BVI 9400

  • Reference: See p.1185 Box 44.5 for detailed usage instructions.

Nursing Process and Alterations in Urinary Function

  • Assessment Areas:

    • Health history including past medical history and lifestyle factors.

    • Physical assessment focusing on signs and symptoms of urinary issues.

    • Assessment of urine characteristics.

    • Diagnostic examinations.

Health History Considerations

  • Comorbidities: Assess conditions like infectious status, diabetes, cognitive impairment, Parkinsonism, arthritis, and sensory impairments.

  • Lifestyle Factors: Include smoking and obesity.

  • Medications: Note medications like diuretics, morphine, and sedatives.

  • Environment and Cognitive Status: Functional abilities are crucial.

Bladder Log

  • A urinary diary detailing fluid intake, output pattern, accidents, urgency, burning, or dribbling.

Physical Assessment

  • Assessment Focus:

    • Signs of dehydration.

    • Perineal area inspection for integrity, rashes, or discharges.

    • Kidney and bladder examination for distention and post-void residual.

    • Assessing for flank pain.

Diagnostic Tests and Examinations

  • Urine Testing:

    • Comparison of urinalysis vs. urine culture.

  • Types of Sample Collection:

    • Clean void or midstream urine collection, catheter specimen, timed void.

Related Nursing Diagnoses

  • Toileting self-care deficit

  • Risk for impaired skin integrity

  • Risk for infection

  • Diagnoses related to stress, self-esteem, personal identity, social isolation, disturbed body image

  • Impaired comfort

  • Pain

Related Goals and Expected Patient Outcomes for Urinary Incontinence

  • Client aims for improved continence, maintained dryness, prevention of UTIs, skin integrity maintenance, and comfort.

Related Goals and Expected Patient Outcomes for Urinary Retention

  • Goals include complete bladder emptying, maintaining appropriate urine volumes, and increased patient comfort.

Interventions

  • Nursing Interventions:

    • Maintain a bladder log.

    • Promote regular voiding patterns.

    • Modify environment meeting functional needs.

    • Maintain skin integrity and prevent infections using incontinence products judiciously.

    • Education on hygiene, hydration, and incontinence prevention.

Pelvic Muscle Exercises

  • Kegel Exercises: Effective for stress incontinence and promoting complete bladder emptying for urinary retention through scheduled toileting and double voiding.

Medical Management

  • Urinary Incontinence:

    • Pharmaceutical Options: Antimuscarinic drugs (e.g., Oxybutynin) for urge or reflex incontinence.

    • Surgical Options: Correct abnormalities in urinary anatomy or physiology.

Medical Management for Retention

  • Chronic Condition: Intermittent catheterization indicated for post-void residuals over 100ml.

  • Acute Condition: Urgent catheterization (indwelling or intermittent) for total inability to urinate.

Indwelling Urinary Catheter Overview

  • Structure: Allows urine to flow and be collected from the bladder.

  • Resources: See Healthwise, Incorporated for detailed applications.

Medical Management for Obstructions

  • Pharmaceuticals: Alpha-adrenergic antagonists (e.g., Doxasozin) for enlarged prostate; 5-alpha-reductase inhibitors (e.g., Finasteride) to reduce prostate size.

  • Surgical Management: Address retention due to obstructions (e.g., TURP).

Nutritional Management

  • Recommendations:

    • Avoid excessive consumption of irritants: citrus juices, carbonated beverages, tobacco, tomato-based products, alcohol, caffeine, greasy/spicy foods, and large fluid intake before bedtime.

Urinary Tract Infections (UTIs)

  • Definition: “The second most common bacterial disease the human body is subject to.” (Lewis et. al., 2014, p.1289)

  • More prevalent in women; over 50% will experience a UTI in their lifetime.

  • Accounts for 40% of hospital-acquired infections, often related to catheterization (CAUTI).

  • Natural Defenses Against UTIs: Includes normal voiding behaviors, complete bladder emptying, and urine's antibacterial properties.

  • Common Causative Microorganisms: Predominantly gram-negative bacteria with E. coli being the most common.

UTI Risk Factors

  • Comorbidities: Diabetes, immunocompromised status, urinary retention, obstructions, previous instrumentation, older age, antibiotics usage.

  • Demographics:

    • Women: Higher risk due to urethra length and proximity to anal orifice; impacted by sexual activity and pregnancy.

    • Men: Risk associated with instrumentation and congenital issues.

UTI Classification

  • Lower Urinary Tract Symptoms (LUTS): Presentation includes dysuria, increased frequency, urgency, suprapubic discomfort; urinalysis may show hematuria or sediment.

  • Upper Urinary Tract Symptoms: Includes flank pain, chills, and fever.

  • Infection Classification:

    • Initial vs. recurrent infections: Recurrent can be further categorized based on persistence and resistance to treatment.

Clinical Manifestations in Older Adults

  • May not present classic symptoms (e.g., can show cognitive impairment, fatigue, absence of fever).

Diagnosis Methods

  • Testing:

    • Dipstick Urinalysis: Measures nitrates, WBCs, blood.

    • Urine Culture: Must be sterile and may require specific collection methods (midstream, catheter).

    • Imaging Tests: e.g., CT scan or IVP for further assessment.

Nursing Assessment for UTIs

  • Health History: Previous UTIs, past health history, and list of medications.

  • Physical Assessment: Monitoring vital signs, identifying symptoms related to urinary issues.

Related Nursing Diagnoses for UTIs

  • Pain (acute)

  • Impaired urinary elimination

  • Ineffective self-health management

  • Risk for infection

Related Goals and Expected Outcomes for UTIs

  • Goals include pain management, normal urinary elimination patterns, adequate fluid intake, and self-care mastery.

Nursing Interventions for UTIs

  • Preventative Strategies:

    • Regular bladder emptying and bowel evacuation, appropriate perineal care (wiping direction), and proper fluid intake.

    • Emphasis on seeking early treatment and appropriate antibiotic use.

    • Education on avoiding irritants like powders or scented products.

  • For Active UTIs:

    • Encourage increased fluid intake to help flush out pathogens, use of local heat for comfort, ensure adherence to prescribed medications, and ongoing patient monitoring.

Medical Management of UTIs

  • Antibiotic Therapy: Duration varies by UTI classification, choice of antibiotics based on culture results. Common treatments include:

    • TMP/SMX: Twice daily for uncomplicated UTIs.

    • Nitrofurantoin: Varies from 3-4 times a day to twice a day for long-acting forms.

    • Fluoroquinolones: For complicated UTIs.

Nutritional Management for UTIs

  • Advocating for consistent fluid intake to dilute urine.

  • Advising against bladder irritants, such as caffeine, alcohol, and specific foods.

  • Cranberry Products: Effective in reducing UTI risk by lower urine pH; must use true cranberry products to be effective.