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Stressors Affecting Elimination

Urinary
NUR101 Fall 2008
Lecture # 22
K. Burger, MSED, MSN, RN, CNE
PPP By
Sharon Niggemeier RN, MSN

Anatomy & Physiology


Kidneys
Ureters
Bladder
Urethra
http://www.youtube.com/watch?v
=glu0dzK4dbU&feature=related

Anatomy & Physiology


MATCHING
Lets test our ?PRIOR? Knowledge of the
renal system.

http://www.freenursetutor.com/urinary/flas
hcards-matching-urinary-system.html

Nephron Function
Functional unit of kidney
1 million per kidney
1200 ml blood pass through the
kidney/min
Wastes cannot be excreted as solids;
must be excreted in solution
Normal urine production = 1 ml / minute
Kidneys must produce 30 ml/hr minimum

Critical Thinking
A client in hemorrhagic shock may proceed
quickly into concomitant renal failure.
Why?
Glomerular capillary blood pressure is the
driving force of glomerular filtration. If blood
pressure is not maintained, there is not enough
osmotic gradient to sustain filtration.

Nephron Function
Blood filtered through glomerulus
this filtrate moves into Bowmans capsules
proceeds into proximal tubule where water
/electrolytes/glucose & protein are reabsorbed
Loop of Henley water and solutes such as Na
& Cl, are reabsorbed (urine becomes more
concentrated)
distal convoluted tubules allows for water and
NA reabsorbtion. Controlled reabsorption (by
ADH antidiuretic hormone) regulates F/E
balance..collecting duct

Act of Micturition
Urine moves from the kidneys through ureters via
peristaltic waves into bladder.
Bladder fills & detrusor muscles sense pressure
Structures and functions for voluntary control of
voiding:
-External sphincter- restrain or interrupt act
-Conscious brain- starts act
-Intact spinal cord- needed or else message from the
brain is not received.

Hmmm.
Why are UTIs more common in women
than in men?

Urethra in women = 1.5 to 2.5 inches


Urethra in men = 6 8 inches

Alterations in Urinary Function


Incontinence- brain is not receiving
impulse or loss of external sphincter
control
Retention- distended bladder due to
nerve impulses not perceived or
muscles unable to function

Characteristics of Urine
Amount
1200 ml/day
average
Color

Turbidity

Odor

Constituents

See Next Slide

pH 4.6 8.0

Specific gravity
1.010 1.025

Get a partner
AND
Describe to them what normal urine smells like.
Ammonia?
Concentrated urine d/t lack of adequate water intact OR
Presence of bacteria in urine OR
Standing urine (urea converts to ammonia when exposed to oxygen)
Eau D Asparagus? Asparagus contains a sulfur compound
called mercaptan. (It's also found in rotten eggs, onions,
garlic, and in the secretions of skunks.) When your digestive
tract breaks down this substance, by-products are released that
cause the funny scent.
Sweet? Uncontrolled Diabetes

Musty? Liver Disease

Factors That Affect Voiding


Food/fluid intake + Life style
loss
Medications
Developmental
factors
See Next Slide

Stress
Activity/Muscle
tone

???

Geriatric Considerations
Decreased ability of kidneys to concentrate urine and
decreased bladder capacity
= nocturia
Decreased muscle tone of bladder
= increased frequency
Decreased bladder contractility & stasis
= increased frequency of UTI
Changes in cognition and mobility (in some)
= increased incontinence issues

Assessing Urinary Status


Usual patterns
Recent changes
Difficulties
Artificial Orifices

Physical Assessment
Kidneys:
R kidney located
12 rib
L kidney lower
Tenderness during
palpation at
costoverterbral
angle?

Bladder:
Below symphysis
pubis
Supine position to
examine
Observe-roundness
Palpate-tenderness,
how high it distends
Percussion- full
bladder dull sound

Assessment: Lab Results


Urinalysis- WBC, RBC, protein,
glucose, bacteria
= abnormal constituents
BUN (blood urea nitrogen) end product of protein
metabolism 10-20 mg/dL
Increased BUN (azotemia) signifies impaired kidney function
affected by diet (hi protein intake) and fluids (dehydration)

Decreased BUN signifies impaired liver function


Many drugs elevate BUN (antibiotics, lasix +++)

Assessment: Lab Results


Serum creatinine - by product of muscle
metabolismexcreted entirely by
kidneys Normal = 0.5-1.2 mg/dL
Increased levels signify renal impairment
BUN: Creatinine ratio- 20:1 when both
rise together indicates kidney failure or
disease

Altered Urinary Functioning


Terms to Know
Anuria
Dysuria
Enuresis
Frequency
Glycosuria
Hematuria
Hesitancy
Frequency

Incontinence
Nocturia
Oliguria
Polyuria
Pyuria
Retention
Urgency
Proteinuria

NCLEX Question
Your client has a urinary tract infection.
Which of the following signs/symptoms
would you expect the client to exhibit?
a. Proteinuria
b. Dysuria
c. Oliguria
d. Polyuria

Assessing Urinary Retention


Feeling of fullness
Voiding small amounts
< 50 ml

Normal intake/inadequate
output
Distended bladder
Discomfort
Bladder Scan
If > 300 ml should catheterize

Nursing Dx R/T Urinary


Elimination
Impaired urinary elimination
Urinary retention

Functional urinary
incontinence
Overflow urinary incontinence

Risk for infection r/t urinary


retention and/or urinary
catheterization

Stress urinary incontinence

Risk for impaired skin integrity r/t


urinary incontinence

Urge urinary incontinence

Situational low self esteem r/t


incontinence

Reflex urinary incontinence

Total urinary incontinence

Outcome Criteria
Patient will:
Empty bladder completely at regular
intervals
Decrease episodes of incontinence
Maintain regular urinary elimination
pattern
Develop adequate Intake/Output
Have decreased dysuria

Nursing Interventions
Maintain voiding habits
Promote fluid intake
Strengthen muscle tone
Kegels 30-80/day

Stimulate urination
Auditory
Tactile

Interventions: Toileting
Toilet
Safety Concerns
Commode
Bedpan
Female Hygiene
Urinal
Disposable Hat
Fx pan

Interventions for Urinary


Incontinence
Bladder training/ Habit training
External urinary device
- Condom Catheter
Indwelling catheter-LAST resort

Condom Catheter (Texas Cath)


Rubber condom placed on penis of
incontinent males
Connects to drainage bag to collect
urine
Easy to apply and observe
Comfortable
Doesnt require intubation
Prevents skin irritation from
incontinence

Condom Catheter
Check every 2-4 hrs.
Remove and replace every 24 hrs.
Maintain free urinary drainage
Never tape to skin
Leave 1-2 inch space at tip of penis
Secure snuggly but not too tight
Follow manufacturer instructions

Urinary Catheterization
Used to:
Keep bladder deflated during surgery
Measure residual urine
PVR (post void residual) should be < 50 ml
Relieve retention
Obtain sterile urine specimen
May use either:
Straight catheter or indwelling catheter

Indwelling catheter
Refer to Lab Worksheet
Catheter inserted into urinary meatus through urethra into
bladder to drain urine
Last resort as it introduces microbes into bladderleading
to UTI (urinary tract infection)
Performed using sterile technique...MD order needed
Remains in place via inflated balloon

ALSO
Suprapubic Catheter diverts urethra
Urologic Stents- temporary in ureters
permanent in urethra
Ileal Conduit diversion of ureters to
ileum and stoma; requires appliance

Medications Affecting Urinary


Elimination
Antibiotics work against infection
Bactrim, Levaquin, Cipro
Urinary antispasmotics relieve spasms with
UTI
Ditropan, Pro-Banthine
Diuretics.increase urinary output
Lasix, Diuril
Cholinergicsincrease muscle tone & function
Used for urinary retention, neurogenic bladder
Urecholine

Urinary Specimen Collection


Refer to Lab Worksheet
Routine urinalysis
Clean-catch/midstream urine
Sterile specimen ( catheterization
or from indwelling catheter)
24 hr. urine

Evaluating Urinary
Elimination
Frequency
Amount
Ease/Difficulty

Color
Appearance
Odor

Complete
Intake and Output Exercise
Handout