Basic Human Needs Urinary Elimination Urinary Elimination Basic

Basic Human Needs Urinary Elimination

Urinary Elimination Basic function that is taken for granted n When the urinary system fails to function properly, all organ systems will be affected n Urinary elimination depends on the function of the kidneys, ureters, bladder, & urethra n

Kidneys n n n Paired, reddish, brown bean shaped organs Location: 12 th thoracic vertebrae to 3 rd Lumbar Left kidney is 1. 5 to 2 cm higher than right, 12 x 7 cm Weight: 120 -150 gms Covered by tough capsule and cushioned by fat

Kidneys Waste products filtered through kidneys n Blood reached kidney via renal artery n 20 -25% of cardiac output circulates to kidneys (1200 ml/min) n

Anatomy of Kidney n n n Nephron-Functional unit of kidney, forms urine Each kidney has 1 million nephrons Nephron composed of glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal tubule, & collecting tubule

Blood Supply Blood reaches kidney via renal artery n Arises from aorta, enters kidney at hilus n Renal artery divides into secondary branches, then into smaller braches to afferent arteriole n

Blood Supply n n To Kidney: Afferent arteriole divides into a capillary network called glomerulus From Kidney: The capillaries unite to form the Efferent arteriole which splits to form peritubular capillaries, drain into venous system > renal vein > inferior vena cava > heart

Physiology of Urine Formation n Normal glomerular function- Urine formation starts at glomerulus where blood is filtered GFR-(Glomerular filtration rate)- amt of blood filtered by glomeruli in a given time Normal GFR- 125 ml/minute, however only 1 ml per minute becomes urine, most is reabsorbed

Tubular Function n n Reabsorption-refers to the passage of a substance from the lumen of the tubules through the tubule cells and into the capillaries Tubular Secretion-passage of a substance from the capillaries through the tubular cells and into the lumen of the tubule

Tubular Function n n Proximal Convoluted Tubule- 80% of electrolytes, glucose, amino acids, protein, reabsorbed Hydrogen & creatinine are secreted into filtrate Loop of Henle - Important in conserving water, reabsorption continues, Descending loopreabsorption of H 2 O, Ascending loopreabsorption of Na & Cl

Tubular Function n Distal Convoluted Tubule- Final regulation of water balance & acid-base balance. Requires ADH (anti-diuretic hormone) for water reabsorption & aldosterone for Na & Cl reabsorption Stimulus for ADH secretion: high serum osmolality, low blood volume Aldosterone secretion influenced by circulating blood volume, plasma concentration of Na &Cl

Tubular Function n Distal Tubule: Acid-Base regulation involves reabsorbing and conserving Bicarb and excretion of excess hydrogen to maintain blood p. H at 7. 35 -7. 45 99% of filtrate is reabsorbed into plasma, 1% excreted as urine Normal 24 hr urine output is 1500 -1600 ml

Hormone Production Erythropoietin n Renin n Angiotensinogen n Kidneys also play a role in Calcium & Phosphate regulation, convert Vitamin D to active form n

Ureters n n n Enter renal pelvis from collecting ducts A ureter joins each renal pelvis to bladder Tubular structures, 10 -12 cm long Peristaltic waves move urine to bladder Obstruction of ureters-renal calculi, strong peristaltic wave-renal colic

Bladder n n n Hollow, distensible, muscular organ (4 layers of muscle) Reservoir for urine Organ of excretion Expands as it becomes filled with urine Pressure within bladder is low 600 ml capacity, normal voiding 300 ml

Bladder Trigone-base of bladder n Muscular layer-detrusor muscle n Parasympathetic innervation stimulates detrusor during urination (smooth muscle contraction) resulting in bladder emptying n

Bladder n n External Sphincter control under voluntary control Sympathetic innervation cause smooth muscle relaxation allowing bladder to fill Internal Sphincter (involuntary) controlled by SNS- cause urethrea to remain closed until person is ready to void Control of Micturition is a result of coordination between the opening of the sphincters and contraction of detrusor

Urethra n n n Urine travels from the bladder through the urethra & passes outside the body through the urethral meatus Lined by mucus membranes, bacteriostatic, forms mucus plug Women-1. 5 -2. 5 inches long, external sphincter allows voluntary flow of urine, prone to infection

Urethra Men-Urethra is both a urinary canal and a passageway for secretions form reproductive organs n 20 cm in length n

Clicker Question 1. A client with long-standing history of diabetes mellitus is voicing concerns about kidney disease. The client asks the nurse where urine is formed in the kidney. The nurse’s response is the: n A. Glomerulus n B. Kidney n C. Nephron n D. Ureter n 45 - 26

Act of Urination Controlled by brain n Coordination of cerebral cortex, thalamus, hypothalamus, & brain stem n Suppress contraction of bladder’s detrusor until person is ready to void n

Act of Urination n Bladder normally holds as much as 600 ml of urine Desire to void is felt(sensed) when bladder contains a smaller amount (150 -200 ml in adult) As bladder volume increases, bladder walls stretch, sending sensory impulses to micturition center in sacral spinal cord

Act of Urination n Parasympathetic impulses from the micturition center stimulate detrusor muscle to contract Internal sphincter relaxes so urine can enter urethra As bladder contracts, nerve impulses travel up spinal cord to the cerebral cortex, now you are aware of the urge to void

Factors Influencing Urination n n n n Disease Growth & Development Sociocultural factors Psychological Factors Muscle Tone Fluid Balance Surgery Medications

Disease n Pre-renal n Renal n Post-renal

Pre-Renal Disease Alterations in urinary elimination resulting from a decrease in circulating blood flow to and through the kidneys with a resultant decrease in perfusion to renal tissue n Alteration is outside the urinary system n

Pre-Renal Disease n Decrease in renal perfusion leads to oliguria (diminished capacity to form urine) or anuria (inability to produce urine)

Pre-renal Conditions Decreased intravascular volume n Dehydration n Hemorrhage n Shock n Sepsis n Anaphylactic Reactions n Cardiac Pump Failure n

Renal Disease n Result from factors that cause injury directly to glomeruli or renal tubule, interfering with normal filtration, reabsorption, & secretory functions

Renal Conditions n n n n Nephrotoxic agents (aminoglycoside antibiotics) Blood transfusion reaction Disease of glomeruli Renal tumors Systemic disease (Diabetes) Infection Hereditary disease (Polycystic kidney disease)

Post-Renal disease Result from obstruction of urinary collecting system from kidney to urethral meatus n Urine is formed but cannot be eliminated n

Post-Renal Conditions Obstruction due to calculi, blood clots, tumors, or stricture n Prostatic hypertrophy or tumor n Neurogenic bladder n Pelvic tumors n

Renal Diseases that cause irreversible damage to the glomerulus or tubules result in permanent alterations in renal function n Chronic Renal Disease n End Stage Renal Disease n Needs treatment for survival n

Uremic Syndrome n n n n Decreased urine output Proteinuria Volume overload CHF Dysrhythmias N/V Uremic frost Anemia

Renal Disease Labs Elevated BUN (7 -26 mg/dl) n Elevated creatinine (0. 7 -1. 5 mg/dl) n Elevated potassium (3. 5 -5. 1 mmol/L) n Elevated phosphate (2. 4 -4. 4 mg/dl) n Decreased calcium (8. 6 -10. 6 mg/dl) n Decreased HCO 3 and p. H (22 -26, 7. 357. 45) n

Uremic Syndrome Increase in nitrogen waste in blood n Fluid and electrolyte disturbance n Treatment either conservative or aggressive n

Renal Disease Treatment Conservative- meds, diet & fluid restriction n Aggressive- Renal Replacement Therapies: Dialysis (Peritoneal or Hemodialysis) n Organ transplantation n

Dialysis Peritoneal-Indirect method of cleansing blood of waste products using the process of osmosis and diffusion n Hemodialysis-machine process utilizes osmosis, diffusion, & ultrafiltration through a vascular graft (Udall, TESIO, Permcath, Shiley) n

Index

Organ Transplantation Replacement of diseased kidney with a healthy one n Compatible blood and tissue type n Sharing Network n Organ Donation card n

Factors Influencing Urination: G & D Infants & young children cannot effectively concentrate their urine n Nocturnal enuresis (bedwetting) n Older adult: difficulty with urination, GFR declines. Kidney’s ability to concentrate urine declines n Nocturia, urinary frequency n BPH in men n Residual urine (UTI’s) n

Factors Influencing Urination: Sociocultural Private toilet facilities (American) communal (Europe) n Social expectations influence time of urination n Must consider cultural, social and gender habits n

Factors Influencing Urination: Psychological Anxiety and emotional stress may cause sense of urgency and increase frequency of urination n Need to relax to void n

Factors Influencing Urination: Muscle Tone Weak abdominal & pelvic floor muscles impair bladder contraction and control of external sphincter n Prolonged immobility, stretching of muscles, menopausal muscle atrophy, damage from trauma, long term catheter use n

Factors Influencing Urination: Fluid Balance n Ingested fluids increase body’s circulating plasma volume which increase urine output n Increased urine formation: coffee, tea, cola drinks n Caffeine is a bladder irritant as well as a diuretic n Alcohol inhibits the release of ADH resulting in increased water loss in urine

Factors Influencing Urination: Surgery n n n Triggers General Adaptation Syndrome ( Increase water reabsorption, reduces urine output Stress response causes increased aldosterone resulting in decreased urine output Anesthetics & narcotics slow GFR decreasing urine output, risk for urinary retention with spinal anesthesia (post-op patients may require hourly urine outputs or if unable to void after surgery, straight catheterization)

Factors Influencing Urination: Medications Diuretics prevent reabsorption of water and certain electrolytes to increase urine output n Urinary retention caused by antihistamines (Sudafed), antihypertensives (Aldomet), & beta blockers (Inderal) n Change color of urine-Pyridium n

Clicker Question A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding: n A. In bathrooms other than their own n B. In a urinal n C. While lying in bed n D. In the presence of person other than their parents 45 - 60

Alterations in Urinary Elimination n Urinary Retention n Urinary Tract Infections n Urinary Incontinence n Urinary Diversions

Urinary Retention n n Marked accumulation of urine in bladder as a result of the inability of the bladder to empty Bladder not able to respond to micturition reflex and empty Retention with overflow may develop, small amt of urine escapes, bladder spasms S&S of bladder distention- discomfort, diaphoresis, restlessness

Lower Urinary Tract Infection n 7 million office visits a year n Most common hospital acquired infection n Most from catheterization or surgery n Bacteria in the urine may lead to the spread of organisms into bloodstream (Urosepsis)

UTI Symptoms Pain or burning on urination (dysuria) n Fever, chills, n/v, malaise (later signs) n Hematuria-irritation of bladder & urethral mucosa resulting in blood-tinged urine n Pyelonephritis-infection spreads up to kidney-flank pain, fever n

Urinary Incontinence Involuntary loss of urine that is a sufficient problem n Temporary or Permanent n No longer have control over micturition n Leakage can be intermittent or continuous n

Urinary Incontinence Functional n Overflow n Reflex n Stress n Urge n

Urinary Diversions Urinary stoma to divert urine from kidneys directly to abdominal surface n Ileal Conduit n Continent Pouch n Ureterostomy n Nephrostomy n

Reasons for Diversions Cancer (Bladder, Prostate, Pelvis, Cervix) n Radiation injury n Vesicovaginal fistula n Neurogenic bladder n Chronic cystitis n Painful Bladder Syndrome/Interstitial Cystitis n

Clicker Question A health care provider may suspect that a client is experiencing urinary retention when the client has: n A. Large amounts of voided cloudy urine n B. Pain in the suprapubic region n C. Small amounts of urine voided 2 to 3 times per hour n D. Spasms and difficulty during urination 45 - 77

Nursing Process Alterations in Urinary Function n n n Assessment: Nursing history Physical Assessment-inspection, percussion, palpation Assessment of Urine- color, clarity, odor Urine testing & specimen collection Diagnostic tests: KUB, IVP, renal ultrasound, renal CT scan Invasive-Cystoscopy, arteriogram, urodymanics

Urine Specimen Collection Random n Clean-voided or midstream n Sterile n Timed specimens (24 hour collection) n

Urine Testing n Uninalysis n Specific Gravity n Urine Culture

Nursing Diagnosis Incontinence n Self-Care deficit n Skin Integrity n Altered Urinary Elimination n Pain n Body Image Disturbance n

Implementation n n Promoting Normal Micturition Medications Catheterization (Indwelling vs. straight) Catheter Irrigations & Instillations Routine Catheter Care/Perineal Care Suprapubic Catheterization External Urinary Cathethers (Condom caths) Female Urinals Maintaining Skin Integrity Preventing Infection

Last Updated: April 1, 2005 Foley catheter Illustration copyright 2004 Nucleus Communications, Inc. All rights reserved. http: //www. nucleusinc. com An indwelling Foley catheter remains in place continuously. To keep the catheter from slipping out, there is a balloon on one end that is inflated with sterile water once that end is inside the bladder. Medical Review: Last Updated: Adam Husney, MD - Family Medicine Nancy Greenwald, MD - Physical Medicine and Rehabilitation April 1, 2005