urinary elimination teresa v. hurley, msn, rn. urinary system kidneys filter nitrogen, metabolic...
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Urinary Urinary EliminationElimination
Teresa V. Hurley, MSN, RNTeresa V. Hurley, MSN, RN
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Urinary SystemUrinary System
Kidneys filter nitrogen, metabolic Kidneys filter nitrogen, metabolic wastes, excess ions and waterwastes, excess ions and water
Urine produced at a rate of 60 Urine produced at a rate of 60 mL/hourmL/hour
Bladder stores average 500 mL or Bladder stores average 500 mL or moremore
Void: detrusor muscle contracts and Void: detrusor muscle contracts and urine is pushed through internal urine is pushed through internal urethral sphincter into urethraurethral sphincter into urethra
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UrinalysisUrinalysis
Urine: clear, yellow, aromatic, Urine: clear, yellow, aromatic, without pathogens or parasiteswithout pathogens or parasites
Specific Gravity: 1.025 (concentrate Specific Gravity: 1.025 (concentrate urine)urine) Increases with dehydrationIncreases with dehydration Decreases with increased fluid intakeDecreases with increased fluid intake
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UrinalysisUrinalysis AbnormalAbnormal
Protein: renal disease, 2Protein: renal disease, 2ndnd to exercise and stress to exercise and stress Glucose: elevated BS; diabetesGlucose: elevated BS; diabetes Ketones: CHO metabolismKetones: CHO metabolism
Diabetes, fever, fasting, starvation, high protein intake, Diabetes, fever, fasting, starvation, high protein intake, vomiting, post-opvomiting, post-op
Hemoglobin: UTI, nephritis, trauma, lithiasis, Hemoglobin: UTI, nephritis, trauma, lithiasis, hemolytic rxhemolytic rx
Bilirubin: liver diseaseBilirubin: liver disease Urobilinogem: cirrhosis, heart failure, pernicious Urobilinogem: cirrhosis, heart failure, pernicious
anemia, monoanemia, mono Nitrates: bacteriaNitrates: bacteria Leukocyte esterase: bacteria, fungal, parasitic, Leukocyte esterase: bacteria, fungal, parasitic,
tumor, nephritistumor, nephritis
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HematologicalHematological
Hematological Hematological BUN 8-16 mg/dL (end product protein BUN 8-16 mg/dL (end product protein metabolism)metabolism)Creatinine 0.6-1.2mg/dL (muscle Creatinine 0.6-1.2mg/dL (muscle metabolism of creatin)metabolism of creatin)
Increased: renal failure, infection, Increased: renal failure, infection, obstruction, dehydration, increase protein obstruction, dehydration, increase protein intake, TPNintake, TPN
Decreased: liver disease, decrease protein Decreased: liver disease, decrease protein intakeintake
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Factors Affecting Factors Affecting MicturitionMicturition
Developmental considerationsDevelopmental considerations Food and fluid intakeFood and fluid intake Psychological variablesPsychological variables Activity and muscle toneActivity and muscle tone Pathologic conditionsPathologic conditions MedicationMedication
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Developmental Developmental ConsiderationsConsiderations
ChildrenChildren Toilet training 18 to 24 months, Toilet training 18 to 24 months,
enuresisenuresis Effects of agingEffects of aging
Nocturia, increased frequency, urine Nocturia, increased frequency, urine retention and stasis, voluntary control retention and stasis, voluntary control affected by physical problemsaffected by physical problems
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Effects of Medications on Effects of Medications on Urine Urine
Production and EliminationProduction and Elimination Diuretics — prevent Diuretics — prevent
reabsorption of reabsorption of water and certain water and certain electrolytes in electrolytes in tubulestubules
Cholingeric Cholingeric medications — medications — stimulate contraction stimulate contraction of detrusor muscle, of detrusor muscle, producing urinationproducing urination
Analgesics and Analgesics and tranquilizers — tranquilizers — suppress CNS suppress CNS diminish diminish effectiveness of effectiveness of neural reflexneural reflex
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Medications Affecting Color Medications Affecting Color of Urineof Urine
Anticoagulants — red colorAnticoagulants — red color Diuretics — lighten urine to pale Diuretics — lighten urine to pale
yellowyellow Pyridium — orange to orange-red Pyridium — orange to orange-red
urineurine Elavil — green or blue-greenElavil — green or blue-green Levodopa — brown or blackLevodopa — brown or black
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Using the Nursing Using the Nursing ProcessProcess
Assessing data about voiding Assessing data about voiding patterns, habits, past history of patterns, habits, past history of problemsproblems
Physical examination of urinary Physical examination of urinary system, skin hydration, urinesystem, skin hydration, urine
Correlation of these findings with Correlation of these findings with results of procedures and diagnostic results of procedures and diagnostic teststests
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Assessing a Problem With Assessing a Problem With VoidingVoiding
Explore its duration, severity, and Explore its duration, severity, and precipitating factors.precipitating factors.
Note client’s perception of the Note client’s perception of the problem.problem.
Check adequacy of client’s self-care Check adequacy of client’s self-care behaviors.behaviors.
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Physical Assessment of Physical Assessment of Urinary FunctioningUrinary Functioning
Kidneys — check Kidneys — check for costovertebral for costovertebral tendernesstenderness
Urinary bladder — Urinary bladder — palpate and palpate and percuss the percuss the bladder or use bladder or use bedside scannerbedside scanner
Urethral meatus — Urethral meatus — inspect for signs of inspect for signs of infection, infection, discharge, or odordischarge, or odor
Skin — assess for Skin — assess for color, texture, color, texture, turgor, and turgor, and excretion of wastesexcretion of wastes
Urine — assess for Urine — assess for color, odor, clarity, color, odor, clarity, and sedimentand sediment
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Measuring Urine OutputMeasuring Urine Output
Ask client to void Ask client to void into bedpan, into bedpan, urinal, or specimen urinal, or specimen container in bed or container in bed or bathroom.bathroom.
Pour urine into Pour urine into appropriate appropriate measuring device.measuring device.
Place calibrated Place calibrated container on flat container on flat surface and read at surface and read at eye level.eye level.
Note amount of Note amount of urine voided and urine voided and record on record on appropriate form.appropriate form.
Discard urine in Discard urine in toilet unless toilet unless specimen is needed.specimen is needed.
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Urine SpecimensUrine Specimens
Routine urinalysisRoutine urinalysis Specimens from infants and childrenSpecimens from infants and children Clean-catch or midstream specimensClean-catch or midstream specimens Sterile specimens from indwelling Sterile specimens from indwelling
cathetercatheter 24-hour urine specimen24-hour urine specimen
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Promoting UrinationPromoting Urination
Maintaining voiding habitsMaintaining voiding habits Promoting fluid intakePromoting fluid intake Strengthening muscle toneStrengthening muscle tone
Kegel Exercises (PFME) to Tx stress, urge Kegel Exercises (PFME) to Tx stress, urge mixedmixed
Imagine voiding, stop flow, tighten rectal Imagine voiding, stop flow, tighten rectal musclesmuscles
Hold 5-10sec and rest 5-10secHold 5-10sec and rest 5-10sec Daily 40-60 PFME doing 2-4 sets of 15 each timeDaily 40-60 PFME doing 2-4 sets of 15 each time
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Client’s at Risk for UTIsClient’s at Risk for UTIs
Sexually active womenSexually active women Postmenopausal womenPostmenopausal women Individuals with indwelling urinary Individuals with indwelling urinary
cathetercatheter Individual with diabetes mellitusIndividual with diabetes mellitus Elderly peopleElderly people
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Four Types of Urinary Four Types of Urinary IncontinenceIncontinence
Stress — increase in intraabdominal Stress — increase in intraabdominal pressurepressure
Urge — urine lost during abrupt and Urge — urine lost during abrupt and strong desire to voidstrong desire to void
Mixed — symptoms of urge and stress Mixed — symptoms of urge and stress incontinence presentincontinence present
Overflow — overdistention and Overflow — overdistention and overflow of bladderoverflow of bladder
Functional — caused by factors Functional — caused by factors outside the urinary tractoutside the urinary tract
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Client Education for Client Education for Urinary DiversionUrinary Diversion
Explain reason for diversion and Explain reason for diversion and rationale for treatmentrationale for treatment
Demonstrate effective self-care behaviorsDemonstrate effective self-care behaviors Describe follow-up care and support Describe follow-up care and support
resourcesresources Report where supplies may be obtained Report where supplies may be obtained
in communityin community Verbalize related fears and concernsVerbalize related fears and concerns Demonstrate a positive body imageDemonstrate a positive body image
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Evaluating Effectiveness Evaluating Effectiveness of Planof Plan
Maintain fluid, electrolyte, and acid-Maintain fluid, electrolyte, and acid-base balancebase balance
Empty bladder completely at regular Empty bladder completely at regular intervals with no discomfortintervals with no discomfort
Provide care for urinary diversion and Provide care for urinary diversion and when to notify physicianwhen to notify physician
Develop a plan to modify factors Develop a plan to modify factors contributing to problemcontributing to problem
Correct unhealthy urinary habitsCorrect unhealthy urinary habits
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Hazards of Hazards of CatheterizationCatheterization
UTI.UTI. Sepsis.Sepsis. Trauma- specially Trauma- specially
in men. in men.
DO NOT USE DO NOT USE FORCE!FORCE!
USE STERILE USE STERILE ASEPTIC ASEPTIC TECHNIQUE!TECHNIQUE!
ResearchResearch clean technique can clean technique can
be used for self be used for self catheterization at catheterization at home.home.
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Reasons for Reasons for CatheterizationCatheterization
Relieving urinary retention.Relieving urinary retention. Obtaining a sterile urine specimen..Obtaining a sterile urine specimen.. Emptying the bladderEmptying the bladder
before,before, during, during, after surgery or diagnostic procedures.after surgery or diagnostic procedures.
Monitoring of critically ill patients.Monitoring of critically ill patients.
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Types of CathetersTypes of Catheters
Indwelling catheterIndwelling catheter remains in place for remains in place for
continuous drainage.continuous drainage. Intermittent catheterIntermittent catheter
used to drain bladder used to drain bladder for short periods of for short periods of time.time.
Suprapubic catheterSuprapubic catheter inserted surgically inserted surgically
above the pubic bone above the pubic bone for continuous for continuous drainage.drainage.
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Urinary DiversionsUrinary Diversions
UreterostomyUreterostomy Bladder is removedBladder is removed One or both ureters redirected from One or both ureters redirected from
kidney through the abdominal wallkidney through the abdominal wall
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Ileal ConduitIleal Conduit
Bladder removed and small intestine Bladder removed and small intestine (ileum) used as conduit between (ileum) used as conduit between ureters and skin surface. Urine ureters and skin surface. Urine collects continuouslycollects continuously
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Client Care Goals:Client Care Goals:Interventions Indwelling Interventions Indwelling
CatheterCatheter Prevent UTI (meatus burning, cloudy, foul, chills, fever)Prevent UTI (meatus burning, cloudy, foul, chills, fever)
Maintain closed systemMaintain closed system Cleanse catheter soap/H2O; pat dryCleanse catheter soap/H2O; pat dry Alcohol swab for contaminationAlcohol swab for contamination Empty bag q 8 h or moreEmpty bag q 8 h or more Bag below bladder levelBag below bladder level Maintain urine acidity: cranberry juice, prunes, plums, Maintain urine acidity: cranberry juice, prunes, plums,
tomatoes, eggs,meat, cheese, citrus fruitstomatoes, eggs,meat, cheese, citrus fruits Change only sediment collects, sandy particles, trouble Change only sediment collects, sandy particles, trouble
drainingdraining
Maintain Urine Flow ( prevent urinary stasis and backflow)Maintain Urine Flow ( prevent urinary stasis and backflow) Gravity drainageGravity drainage Check for kinks, coils, lying on tube Check for kinks, coils, lying on tube Clamp if higher than bladderClamp if higher than bladder Do not allow on floorDo not allow on floor
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Client GoalsClient Goals Prevent Infection TransmissionPrevent Infection Transmission
Wash hands before and afterWash hands before and after Wear glovesWear gloves
Promote Urine Production (pathogen Promote Urine Production (pathogen flushing; tube irrigation; prevents stasis)flushing; tube irrigation; prevents stasis) Oral intake 8-10 glasses (3000 mL/day) unless Oral intake 8-10 glasses (3000 mL/day) unless
contra-indicatedcontra-indicated Parenteral or Enteral feedingsParenteral or Enteral feedings Monitor I & O q 8 hMonitor I & O q 8 h Check for blood, sediments, color, odorCheck for blood, sediments, color, odor
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Client GoalsClient Goals
Maintain Skin and Mucosal IntegrityMaintain Skin and Mucosal Integrity Prevent fecal and encrustation to Prevent fecal and encrustation to
catheter and perineal areacatheter and perineal area Cleasnse: soap/H2OCleasnse: soap/H2O Sandy particle encrustation at the Sandy particle encrustation at the
meatus (catheter change) meatus (catheter change)