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Chap 37

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Elizabeth E

on 21 November 2013

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Transcript of Chap 37

Chap 37
Urinary Elimination
I. Anatomy and Physiology
A. Kidneys and Ureters
-kidneys filter and excrete blood constituents that are not
needed and retain those that are
-nephron -> basic structural and functional unit of the
kidney (a million nephrons) each removes urea, cr, and uric
acid from the blood plasma and urine
-once formed urine empties in pelvis of kidney and transported
by rhythmic peristalsis through the ureters to the bladder
B. Bladder
-smooth muscle sac (temp reservoir) with 3 layers
-detrusor muscle
-internal sphincter: involuntary
-SNS (retain urine) inhibits bladder and motor impulses to the
internal sphincter, detrusor muscle relaxes and sphincter
constricts
-PNS (pee) detrusor contracts + sphincter relaxes
-when pressure becomes sufficient, the person will feel desire
to empty bladder (stretch receptors)

C. Urethra
-function: transport urine from bladder to outside of
body
-external sphincter: voluntary control
-females shorter: risk for infection

D. Act of Micturation
-process of emptying the bladder (voiding, urinating)
-stretch receptors in the bladder are stimulated when
urine collects
-the person feels a desire to void when the
bladder fills to about 150 to 250 ml
-when brain no longer controls bladder:autonomic bladder
-women cough, sneeze -> urinary incontinence

E. Frequency of Urination
-pt should go every 3-4 hours to prevent harboring
bacteria
-urinary retention: occurs when urine is produced normally
but is not excreted completely from the bladder
II. Factors Affecting Urination
A. Developmental Considerations
-children develop urinary control b/w 2-5 yo
1. Toilet training
2. Effects of Aging
>incontinence
>nocturia
>decreased bladder muscle tone -> causes increased
frequency of urination
>decreased muscle contractility may lead to retention
which can cause infection
>neuromuscular problems, joint probs, ALOC, weakness
may interfere with control and ability to reach toilet
in time
>meds: diuretics
sedatives and tranquilizers may diminish
awareness of need to void



B. Food and Fluid Intake
-when the body is dehydrated, the kidneys reabsorb
fluid, so the urine produced is more concentrated and
is decreased in amount (specific gravity will be >1.025)
-caffeine has a diuretic affect
-alcohol inhibits release of ADH which causes us to pee
-high Na+ -> retain urine

C. Psychological Variables
-privacy and stress

D. Activity and Muscle Tone
- activity allows for optimal urine production and
elimination
-immobility causes decreased muscle tone can resulty
in poor urinary control and urinary stasis
-indwelling catherter (you lose muscle tone)
-child bearing, menopause, damage to muscle
-DO KEGAL EXERCISES
E. Pathologic Conditions
-Renal failure
-DM (increased urination)
-CHF (decreased UO)
-Paralysis, UTIs, fever, etc all interfere with
urinary elimination

F. Medications
-nephrotoxic
>abuse of ibuprofen/aspirin
>gentamicin
-diuretics (increase frequency and amount)
-cholinergics: stimulate contraction of
detrusor muscle
-analgesics: decreased sensation to void
-anticoagulants: hematuria
-pyridium: orange urine
-vitamin B- green/blue urine
-Levodopa: brown/black urine
The Nursing Process
for Urinary Elimination

A. Assessing
-usual voiding habits? difficulties? urinary diversions?
-Bladder: located below symphysis pubis and cannot
be palpated when empty
>assess for distention.
>when did they last void?
>bladder scanner to measure volume
-Urethral Orifice: inflammation? discharge? odor?


Urine Characteristics: Table 37: 1
-Color: pale, yellow, straw-colored, amber
(urine is darker when it's concentrated)
-Odor: aromatic, if you let urine stand it develops
ammonia odor
(infected urine has fetid odor)
-Turbidity: fresh urine should be clear and translucent
as urine stands it turns cloudy
(cloudiness in fresh urine is abnormal)
-pH: normal is about 6.0 (4.6 to 8)
-specific gravity: a measure of the concentration
of dissolved solids in the urine
range is 1.015-1.025
(concentrated urine will have a higher than
normal specific gravity. Usually indicates
dehydration. Low would be overhydration)
-urine constituents:

>organic: urea
uric acid
creatinine
hippuric acid
indican
urene pigments
nitrogen
>inorganic: ammonia
Na+, Cl-, iron, phosphorus, sulfer,
K+, Ca++
ABNORMAL constituents:
-blood
-pus
-albumin
-glucose
-ketone bodies
-casts
-gross bacteria
-bile
Renal Function studies:

serum osmolarity: 280-295 mOsm/kg

BUN: 10-20 mg/dl
>an increased level: renal failure >20 mg/dl
DEHYDRATION
>a decreased level: malnutrition <10 mg/dl
FVE

Creatinine: males: 0.6-1.2 mg/dl
females: 0.5-1.1 mg/dl
>increased level- renal impairment
>decreased level- decreased muscle mass

Bun/Cr RATIO 12:1 to 20:1
3. Special Assessment Techniques
-collection urine specimens
> 24 HOUR URINE SPECIMEN
-collect all urine voided in a 24 hr period
-place sign on door as a reminder, tell fam, CNA
-get container from lab with preservative or keep on ice
-(the whole foley bag on ice)
-initiate a collection at a specific time (which is recorded) by
asking the pt to empty bladder. Discard this urine and then
collect all the urine voided for the next 24 hrs
-at the end of this 24 hrs ask the pt to void and add it to
previously collected urine and send entire specimen to lab
-may need more than one container. KEEP ON ICE
-if one gets full, senf to lab (time/date) and let them know
24 hrs is not up yet
g) Diagnostic Tests
>Intravenous Pyelogram (IVP)
-aka excretory urography
-most common
-radiographic exam of the kidney + ureter after a
contract material is injected IV.
-used to dx kidney and ureter disease and impaired
renal function
-preparation:
>withhold (NPO) or limit fluids or foods before test
>obtain pts allergies: shellfish? iodine?
>test is contraindicated for pts with elevated
BUN/cr, also if they're pregz
>elderly, debilitated or young pts may not tolerate
this dehydration
>give laxative/enema so that stool does not
interfere with visualization (morning of)
>obtain and signed consent form
>tell pt to void before exam

-aftercare:
>OFFER FLUIDS and food immediately after exam
>provide sufficient fluids to replace the ones lost
during pretest period
>observe for s/s of allergies/hives/ rash/ N/V
>contrast may initiate acute renal failure
monitor I/O


B. Dx
-Urge urinary incontinence
-urinary retention
-Anxity/ Risk for infection

C. Outcome/Planning
-the pt will produce a balance I+O
-maintaun fluid and electrolyte imbalance
-empty bladder completely at regular intervals
-report ease of voiding
-maintain skin integrity
D. Implementing
-Promoting Normal Urination
>maintain normal voiding habits
-schedule, urge to void, privacy, position,
hygiene
>maintain fluid intake 2-3 L
>strengthening muscle tone
-KEGAls
>assist with toileting

-Prevent UTIs
>identify early
>s/s dysuria, cloudy urine, foul odor
>teach pt how to prevent
Types of Urinary Incontinence
-transient
-stress
-urge
-overflow
-functional
-reflex
-total

The postvoid residual (PVR) urine (the amount of
urine remaining in the bladder immediately after
voiding) can be measured by scanner or cath.
>
a PVR or less than 50 ml indicates adequate
bladder emptying
>
A PVR greater than 150 ml is often recommended
as guideline for catherization b/c residual urine
volumes of greater than 150 ml have been
associated with development of UTI
Try not to use pads b/c of risk for skin breakdown
and UTI.

When to use catherization
-pt is unable to urinate, pt's bladder is full,
pt is going to surgery

>Types: condom catheter (vigilant skin care)
intermittent urethral catheter
indwelling urethral catheter
suprapubic catheter
-Caring for a pt with a urinary diversion
>urine is excreted through a stoma
STOMA CARE
-should be dark pink to beefy red
-moist and smooth
-a pale stoma may indicate anemia
-a dark or purple/blue stoma may indicate ischemia
-bleeding should be minimal
-note size of stoma
-keep clean and dry
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