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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
-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
-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
-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
>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
-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
E. Pathologic Conditions
-Renal failure
-DM (increased urination)
-CHF (decreased UO)
-Paralysis, UTIs, fever, etc all interfere with
urinary elimination

F. Medications
>abuse of ibuprofen/aspirin
-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
hippuric acid
urene pigments
>inorganic: ammonia
Na+, Cl-, iron, phosphorus, sulfer,
K+, Ca++
ABNORMAL constituents:
-ketone bodies
-gross bacteria
Renal Function studies:

serum osmolarity: 280-295 mOsm/kg

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

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
-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
>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

>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,
>maintain fluid intake 2-3 L
>strengthening muscle tone
>assist with toileting

-Prevent UTIs
>identify early
>s/s dysuria, cloudy urine, foul odor
>teach pt how to prevent
Types of Urinary Incontinence

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
-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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