Health Differences: Ch 37, Urinary Elimination

Chapter 37, Urinary Elimination

Taylor's Fundamentals of Nursing

Chapter Outline

ANATOMY AND PHYSIOLOGY

Kidneys and Ureters

• kidneys help maintain the composition and volume of body fluids
• the body's total blood volume passes through the kidneys once q30m for waste removal
• the nephron is the basic structural and functional unit of the kidneys (~1 million/kidney)
• nephrons remove the end products of metabolism (urea, creatinine, uric acid)
• a fold of membrane in the bladder closes the entrance to the ureters to prevent back flow when pressure exists in the bladder

Bladder

• smooth muscle sac that serves as temporary reservoir for urine
• composed of three layers: the inner longitudinal, middle circular, and outer longitudinal. These three layers collectively make up the detrusor muscle
• at the base of the bladder is the internal sphincter which guards the opening between the bladder and the urethra
• the urinary bladder is innervated by the autonomic nervous system
• the sympathetic system carries inhibitory impulses to the bladder and motor impulses to the internal sphincter
• the parasympathetic system caries motor impulses to the bladder and inhibitory impulses to the internal sphincter
• when the pressure becomes sufficient to stimulate nerves an the bladder wall (stretch receptors), the person feels a desire to empty the badder

Urethra

• functions to transport urine from bladder to the exterior of the body
• the external sphincter in under voluntary control
• note the differences between the male and female urethra

Act of Urination

• the process of emptying the bladder is known as urination, micturition, or voiding
• urination is a largely involuntary reflex, but its control can be learned
• desire to void coors when the badder fills to ~150 to 250ml in an adult
• the pressure in the bladder is many times greater during urination than the time the bladder is filling
• when urination is initiated, the detrusor muscle contracts, the internal sphincter relaxes, and urine enters the posterior urethra. the muscles of the perineum and external sphincter relax, the muscle of the abdominal wall contracts slightly, the diaphragm lowers, and urination occurs
• urination is normally painless
• any involuntary loss of urine is referred to as urinary incontinence
• the voluntary control of urination develops as the higher nerve centers develop after infancy, until that time, voiding is pursy a reflex action
• people whose bladders are no longer controlled by the brain because of injury or disease also void by reflex only this is called autonomic bladder

Frequency of Urination

• dependent upon the amount of urine being produced
• most healthy people do not void during normal sleeping hours
• the first voided urine of the day is usually the most concentrated of the day
• because 1st void of the day is not fresh it may or may not be used for certain tests
• people who habitually urinate infrequently develop ore UTI's and kidney d/o's than those who void q3-4h. this is believed to be due to the stagnation of urine in the bladder which serves as a good medium for bacterial growth
• urinary retention occurs when urine is produced normally but is not excreted completely from the bladder
• factors associated with urinary retention are medications, an enlarged prostate, or vaginal prolapse

FACTORS AFFECTING URINATION

Developmental Considerations

• Infants are born without voluntary control or ability to concentrate urine
• urine is light in color and without odor
• @ ~ 6 weeks the infants nephrons are able to control reabsorption of fluids into the tubules and effectively concentrate urine
• most children develop control between 2 and 5 years
• daytime control precedes nightime
• girls develop control earlier than boys (generally)
• older children and adults seldom wake to void d/t kidneys ability to concentrate urine and produce less at night an decreased renal blood flow

Toilet Training:

• voluntary control of the urethral sphincters occurs between 18 and 24 months
• toilet training begins @ ~ age 2-3 years
• toilet training should not begin until chid can: hold urine for 2 hours, recognize feeling of bladder fullness, communicate need to void and control urination until seated on toilet
• occasional daytime incontinence of urine in a child is usually not a cause for concern

Effects of Aging:

Physiologic changes that accompany normal ages may affect urination. These changes include:

• diminished ability of kidneys to concentrate urine may lead to nocturia
• decreased bladder muscle tone may reduce capacity for bladder to hold urine
• decreased contractility may lead to urinary retention and stasis, which increases likelihood of UTI
• neuromuscular problems, degenerative joint problems, metal alterations, weakness- interfere with voluntary control and ability to reach toilet in time
• Diuretics cause increased urine production, resulting in need for increased urination and possibly urge incontinence
• sedatives and tranquilizers may diminish awareness of need to void

Food and Fluid Intake

• kidneys help body maintain careful balance of fluid intake an output, which should be about equal
• when the body is dehydrated the kidneys reabsorb fluid and urine is more concentrated and decreased in amount
• conversely, with fluid overload, kidneys produce a large volume of dilute urine
• caffeine containing beverages (cola, coffee, tea) have a diuretic effect
• alcohol inhibits the release of antidiuretic hormone
• foods and beverages with high sodium content cause sodium and water reabsorption and retention, thereby decreasing urine formation

Psychological Variables

• individual, family, and sociocultural factors affect voids habits
• for some it is personal and private
• assistance can provoke embarrassment and anxiety
• some people that experience stress void in smaller more frequent amounts
• stress can interfere with the ability to relax they perineal muscles and external sphincter

Activity and Muscle Tone

• during prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis
• people with indwelling catheters can lose bladder tone because the bladder is not being stretched
• other causes of decreased muscle tone include: childbearing, muscle atrophy due to decreased estrogen as seen with menopause, and damage to muscles from trauma

Pathologic Conditions

• certain renal or urologic problems can affect quantity and quality of urine produced
• renal failure is a condition in which the kidneys fail to remove metabolic end products from the blood and are unable to regulate fluid, electrolyte, and pH balance
• acute renal failure is a sudden decline in kidney function and may be caused by: severe dehydration, anaphylactic shock, pyelonephritis, and ureteral obstruction
• chronic kidney disease is the end result of irreparable damage to the kidneys, developing slowly over many years
• chronic renal failure is caused by conditions such as diabetes, hypertension, and glomerulonephritis
• fever and diaphoresis result in fluid conservation by the kidneys. urine production is decreased and urine is highly concentrated
• other pathologic conditions such as CHF, may lease to fluid retention an decreased urine output
• high blood glucose levels, such as with diabetes mellitus, may lead to an increase in urinary output 2/2 an osmotic diuretic effect

Medications

• meds have numerous effects on urine production and elimination
• nephrotoxic- having ability to cause kidney damage
• abuse of analgesics such as aspirin or ibuprofen (advil) can cause nephrotoxicity
• some antibiotics, such as gentamicin, can be nephrotoxic
• diuretics prevent the reabsorption of water and certain electrolytes in tubules
• cholinergic medications can stimulate the contraction of the detrusor muscle and produce urination
• some analgesics and tranquilizers suppress the central nervous system , interfering with urination by diminishing the effectiveness of the neural reflex
• Certain drugs cause changes in urine color as in the following:

1. anticoagulants may cause hematuria, leading to a pink or red color
2. diuretics can lighten urine to pale yellow
3. pyridium can caused orange-red color
4. antidepressant amitriptyline (elavil) or B complex vitamins can cause green or blue green
5. Levodopa (l-dopa), an anitparkinson drug, and injectable iron compounds can lead to dark brown or black urine

The Nursing Process for Urinary Elimination

Assessing

• Collection of data: voiding patterns, habits, difficulties, hx of current or past problems
• Physical examination of bladder, if indicated, and of urethral meatus; assessment of skin integrity and hydration;examination of the urine
• Correlation of these findings with results of tests and examination

Nursing History:

• question pt on habits and current or past difficulties: patterns of elimination, changes in elimination, aids to elimination, present or past voiding difficulties, presence of artificial orifices (i.e. ileal conduit)
• with infant assess the number of wet diapers per day. newborns should have minimum 6 wet diapers/day
• with young children assess day and nighttime bladder control
• pts with urinary diversions may have specific care routines
• a urinary diversion involves the surgical creation of an alternate route for excretion of urine
• when pt or caregiver reports prob, explore its duration, severity, and precipitating factors
• also note pt's perception of prob and set care procedures

Physical Assessment:

Physical assessment of urinary functioning includes: examination of bladder, urethral meatus, skin, and urine Kidneys are protected by fat and connective tissue and should only be palpated as part of a more detailed assessment and usually by an advanced practitioner.

BLADDER:
Assessment of bladder may be indicated when there is difficulty voiding or other alterations in elimination. Bladder is normally positioned below the symphisis pubis and cannot be palpated or percussed when empty. When distended, it rises above  the symphisis pubis and may reach to just beneath the umbilicus.
A bedside scanner is another way to assess the bladder. The scanner creates an image of the pts bladder and measure the amount of urine present. This is noninvasive and painless, can be performed at the bedside, poses no risk for infection, and is safer than catheterization to assess bladder urine volume. Results are most accurate when pt is in supine position.

URETHRAL OROFICE:
Inspect for signs of inflammation, discharge, or could odor.

SKIN INTEGRITY AND HYDRATION:
Assess the skin carefully for color, texture, and turgor.

URINE:
Assess for color, odor, clarity, and presence of sediment.
Inselect pts monitor pH and specific gravity and check for abnormal constituents such as protein, blood, glucose, ketone bodies, and bacteria.
*The measurement of fluid intake and output may be delegated to unlicensed personnel however, nurse must validate accuracy of the measurements.

MEASURING URINE OUTPUT IN PATIENTS WHO ARE INCONTINENT:

Note number of time pt is incontinent and urine characteristics. Additional interventions are required to measure urine accurately. Scheduled toiling can help.

Collecting Urine Specimens:

Different techniques are used for collecting urine specimens.

ROUTINE URINALYSIS:

• sterile procedure is not required for routine urinalysis
• pt can void into clean bedpan, urinal, or receptacle
• avoid contamination with feces
• do not leave urine sitting at room temp for too long because it may alter the appearance and chemistry of the sample

CLEAN-CATCH OR MIDSTREAM SPECIMEN:

• most healthcare agencies require that clean catch be collected midstream
• the first amount of urine voided helps to flush away organisms at the meatus
• it is generally thought that urine voided midstream is most characteristic of what the body is producing

STERILE SPECIMEN:

• may be obtained by catheterizing a pts bladder or by taking a sample from an indwelling cath already in place
• when collating form indwelling cath use the special port for specimens, not from collecting receptacle bc it is not fresh and may result in inaccurate results
• urine culture requires ~ 3mL
• urinalysis requires at least 10mL
• if urine is not present, clam tube below access and port and wait ~ 30 min to allow urine to accumulate

24 HOUR SPECIMENS:

• for some studies, 24 hour collection is required
• depending on type of test urine may be combined or kept separately

Point of Care Urine Testing:

• may be done at bedside or in an office
• may test for glucose, bilirubin, protein, bacteria, and blood
• economic and fast yet lab analysis needed for precise results

Outcome Identification and Planning
Nursing interventions should support planned pt outcomes. The pt will:

• produce urine output ~ equal to urine intake
• maintain fluid and electrolyte balance
• empty the bladder completely at regular intervals
• report ease of voiding
• maintain skin integrity

Implementing

Nursing interventions focus on maintaing and promoting  normal urinary function, improving or controlling incontinence, preventing potential problems associated with bladder cath, and assisting with care of urinary diversions.

Promoting Normal Urination:

Interventiosn to support normal voiding habits, fluid intake, strengthening of muscle tone, stimulating urination and resolving urinary retention, and assisting with toiling. 

NANDA Nursing Diagnoses for Urinary Elimination:

1. Impaired Urinary Elimination- sensory motor impairment, urinary tract infection, anatomical obstruction. Urinalysis reveals hematuria and proteinuria.
2. Functional Urinary Incontinence- altered environment, sensory, cognitive, or mobility deficits
3. Reflex Urinary Incontinence- neurologic impairment, age-related degenerative changes, high intra-abdominal pressure, incompetent bladder outlet. Pt with spinal cord lesion reports no awareness of bladder filling, no urge to void or feelings of bladder fullness, involuntary loss of urine at somewhat regular intervals
4. Stress Urinary Incontinence- over distention between voidings, weak pelvic muscles and structural supports. involuntary leakage of urine with sudden movement, sneezing, coughing, and laughing
5. Total Urinary Incontinece- neurologic impairment, trauma or disease affecting spinal cord nerves. Constant flow of urine at unpredictable times without distention. Nocturia. Unawareness of incontinence.
6. Urge Urinary Incontinence- decreased bladder capacity, bladder spasms, increased intake of caffeine or alcohol, increased urine concentration, over distention of bladder. Urgency, frequency, nocturne, bladder contracture or spasm.
7. Urinary Retention- high urethral pressure caused by weak detrusor muscle, inhibition or reflex arc, strong sphincter, blockage. 

Self Care Behaviors for Urine Elimination:

• Maintain a normal voiding volume and pattern 
• Respond as soon as possible to the urge to go
• Drink 8-10 glasses of water daily
• Avoid foods that have access sodium
• Monitor use of caffeine, alcohol, or med schedules that promote voiding and may interfere with sleep.
• Seek medical assistance for any changes in characteristics of urine or presence of pain on urination.

Promoting Fluid Intake:

• adults with no disease-related fluid restrictions should drink 2-2400mL of fluid daily
• that drinking this much will cause weight gain and fluid retention is a misconception
• patients who are confused and children may need to be reminded to drink
• monitor for excessive amounts of caffeine, high sodium, and high sugar beverages

Strengthening Muscle Tone:

• weakening of the pelvic floor muscles is a common cause of incontinence
• pelvic floor muscle training (PFMT) can improve voluntary control of urination and significantly reduce or eliminate problems with stress incontinence
• PFMT exercises are commonly called Kegel exercises
• the muscles to exercise are the same muscles that the pt uses to stop urine midstream or to control defecation
• they should be practiced 30 to 8- times a day for 6 weeks or until symptoms improve

Preventing Urinary Tract Infections:

UTI's are the leading cause of morbidity and healthcare expenditures in persons of all ages. They are the leading cause of systemic infections in oder adults.

Risk Factors (for UTI'S)

• Sexually active women: During intercourse bacteria can migrate to the urethra and bladder
• Women who use diaphragms for contraception: the spermicide used with a diaphragm decreases the amount of normally protective flora
• Postmenopausal women: Urinary stasis provides an optimal environment for bacteria to multiply; in addition, decreased estrogen contributes to decreased protective flora
• Individuals with an indwelling urinary catheter: about half of all pts with an indwelling catheter become infected within one week of its insertion. Most pathogens are introduced via handling of the catheter and drainage device after placement
• Individuals with diabetes mellitus: glucose in the urine acts as an excellence medium for bacteria to proliferate
• Elderly people: physiologic changes associated with aging predispose older people to development of UTI's

Diagnostic Evaluation:

• in addition to history and physical examination, labs findings can identify the presence of a UTI
• urine sample should be clean catch or sterile specimen
• a C&S is positive if at least 100,000 organisms per mL of urine are present
• lower counts may be significant if pt has signs and symptoms of UTI
• presence of bacteria in a clean catch midstream or sterile urine specimen, accompanied by symptoms (dysuria, frequency, urgency, cloudy urine, foul odor), indicates a UTI
• RBC's and nitrates may also be present

Treatment:

• short course antibiotic regimen ( 1 large dose vs 3 or 7 days of smaller doses) usually eradicates lower UTI
• Upper UTI require longer antimicrobial therapy
• drink 8-10, 8oz glasses water/day
• observe urine for color, odor, and frequency
• dry perineal area from front to back
• 2 glasses of water before and after intercourse and void immediately after intercourse
• take showers rather than baths
• wear underwear with cotton crotch
• drink cranberry or blueberry daily- can help with bacteriuria by inhibiting bacteria from adhering to the bladder wall and urinary catheters

Caring for an Incontinent Patient:

• urinary incontinence is widely underreported and under diagnosed
• it is one of the most common chronic health problems
• more prevalent in women and increases with age
• of those who seek treatment, 80% are cured or have improved symptoms
• pts frequently turn to absorbent products when not treated
• when used improperly, absorbent products can lead to skin breakdown and place the pt at risk for UTI
• advertisements for absorbant items increase public awareness about urinary incontinence but fail to mention possible treatment strategies

Types of Urinary Incontinence:

• Transient Incontinence: appears suddenly and usually lasts 6 months or less, usually caused by treatable factors 
• Stress Incontinence: occurs when there is an involuntary loss of urine related to increased intra-abdominal pressure (coughing, laughing, sneezing)
• Urge Incontinence: involuntary loss of urine after feeling an urgent need to void
• Mixed Incontinence: indicates there is one or more type of urine loss
• Overflow Incontinence: involuntary loss of urine associated with over distention and overflow of the bladder. The signal to empty the bladder may be under active or absent. May be 2/2 drugs, fecal impaction, or neurologic conditions
• Functional Incontinence: urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation.
• Reflex Incontinence: emptying of the bladder without the the sensation of the need to void
• Total Incontinence: continuous and unpredictable loss of urine, resulting form surgery, trauma, or physical malformation. Urination cannot be controlled due to anatomic abnormality.

Assessment:

• voiding diaries or records can provide info about frequency, timing, and amount of voiding.
• by noting patterns the nurse may find correlations with medications, fluid intake, or other causes of incontinence and may be able to prevent further episodes
• diaries can also be used to evaluate effectiveness of interventions
• Postvoid Residual (PVR) urine (the amount of urine remaining in the bladder immediately after emptying) can be measured by the use of a portable ultrasound device that scans the bladder
• bladder scan poses no risk for infection and is considered a safer alternative to catheterizations
• a PVR of less than 50 mL indicates adequate bladder emptying 
•  a PVR of greater than 150 mL is often used as a guideline for catheterization because residual volumes of greater than 150 mL have been associated with development of UTI's

Treatment:

• non-invasive, low risk, behavioral interventions are the first line of therapy for incontinence
• many pts incorrectly believe than surgery is the only treatment option for incontinence
• surgical intervention is only recommended when behavioral and pharmacologic measures prove ineffective 

Behavioral Treatment Techniques:

• pelvis floor exercises
• biofeedback- measuring devices to help pt become aware when pelvic muscles are contracting
• electrical stimulation- electrodes placed in vagina or rectum that stimulate nearby muscles to contract
• timed voiding or bladder training
• urgency control is addressed using distraction and relaxation techniques

Pharmacologic Treatment:

• some medications inhibit contractions of the bladder, other may relax muscles, and some may tighten muscles at the bladder neck and urethra
• estrogen may be used in post menopausal some to relieve atrophy of involved muscles
• collagen may be injected into the tissue around the urethra to add bulk and help close the urethral opening

Mechanical Treatment:

• Pessaries: a stiff ring that is inserted into the vagina, where it help ti reposition the urethra. May be placed by patient or nurse.
• External Barriers: adhere to urethral opening to stop urine leakage. Small foam pad placed over the urethral opening. Seals against body to keep urine from leaking. Removed and discarded before pt voids.
• Surgical intervention used as a last resort. Type of surgery depends on cause of incontinence.

Catheterizing the Patient's Bladder:

Catheter-assocaited urinary tract infections are the most common hospital acquired infection in the United States and should be avoided whenever possible. When deemed necessary, it should be performed using aseptic technique and left in place for the shortest length of time possible. The duration of catheterization is the most important risk factor for development of a urinary tract infection.

Important Considerations about the Lower Urinary Tract:

When planning catheterization, consider the following:

• The bladder is normally a sterile cavity
• The external opening to the urethra can never be sterilized
• The bladder has defense mechanisms. It empties itself of urine regularly and maintains an acidic environment which has antibacterial advantages. These help to keep it sterile and clean.
• Pathogens introduced to the bladder can ascend the ureters and cause bladder and kidney infections
• A healthy bladder is not as susceptible to infection as an injured one. States of lowered resistance (diseases and stress) can predispose pts to UTI

Types of Catheters:

• Intermittent Urethral Catheters (straight catheter)- used to drain bladder for short period of time. Most research supports clean, rather than sterile technique, when using straight cath.
• Indwelling Cath- also called retention or foley catheters. designed to not slip out of the bladder. held in place by inflated balloon inside the bladder. double or triple lumen.
• Suprapubic Cath- for long term continuous drainage. diverts urine from urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised flow of urine through urethra. also associated with decreased risk of contamination with organisms from fecal matter, elimination of damage to urethra, higher rate of pt satisfaction, lower risk of catheter-associated UTI's

Reasons for Urinary Catheterization:

Common reasons for catheterization include:

• Relieving urinary retention. Retention is common after surgery involving lower abdomen, pelvis, bladder, or urethra or any mechanical obstruction
• Obtaining a sterile urine specimen
• Obtaining a urine specimen when a specimen cannot be secured by other means
• Emptying the bladder before, during, or after surgery or diagnostic exams
• Monitoring critically ill pts

Hazards of Catheterization:

• sepsis and trauma
• bacteriuria
• in males catheter should be inserted to the catheter bifurcation to avoid inflating the balloon in the urethra
• report any signs of infection: burning and irritation, cloudy urine, strong odor to urine, elevated temp, chills
• change indwelling cats only as necessary

Caring for a Patient with a Urologic Stent:

• when pt has a urinary tract obstruction, a urologic stent may be inserted
• never irrigate a blocked stent
• instruct the pt to notify the PCP 
• encourage pt to wear a medical alert bracelet

Caring for a Patient With a Urinary Diversion:

• Divert the flow of urine surgically. 
• Ileal conduit is a cutaneous urinary diversion
• Ileal conduit- involves a surgical resection of the small intestines with transplantation of the ureters to the isolated segment of small bowel,separated section of small intestine is brought to abdominal wall, where urine is excreted through a stoma,usually permanent
• Urosotmy- uses section of intestine to create an internal reservoir that holds urine. must be cath'd intermittently.
• Mitrofanoff Procedure- bladder neck is closed, appendix is used to gain access to bladder from skin surface. one end of appendix is brought to skin and used as stoma, the other end is tunneled into the bladder. must be cath'd intermittently.

General Care Guidelines for Stoma:

• Inspect regulary. Should be dark pink to red and moist. Pale could indicate anemia, dark or purple blue could indicate compromised circulation or ischemia. Bleeding should be minimal.
• Size stabilizes with 6-8 weeks. Most protrude 1/2 to 1" from skin and may be swollen at first. 
• Keep skin around site clean and dry to avoid candida or yeast infection.
• Measure pts intake and output to access function of the diversion
• Keep pt free of odors
• Monitor return of intestinal function
• If pt has ileal conduit mucous may appear in urine
• Explain care to pt
• Encourage pt to participate in care and look at stoma

Patient Education:

• explain reason for diversion
• demonstrate self care methods to care for diversion
• describe follow up care and existing support resources
• explain where supplies may be found in the community
• verbalize related fears and concerns
• promote a positive body image

Care for a Patient Receiving Dialysis

• dialysis is used to treat pts that experience severely decreased or total loss of kidney function
• mechanical way of filtering blood
• 2 categories- hemodialysis and peritoneal

Evaluating Plan of Care to Promote Healthy Urinary Function

Nursing care is considered effective if the pt expresses satisfaction with the regular voiding pattern and is able to:

• produce a sufficient amount of urine to maintain fluid, electrolyte, acid base balance
• empty bladder completely at regular intervals without discomfort
• provide care for urinary diversion and know when to notify PCP
• develop a plan to modify any factors that contribute to current urinary problems or that might impair urinary functioning in the future
• correct unhealthy urinary habits such as delaying voiding, drinking insufficient fluids, or abusing diuretics