Elimination wangkfsdu edu cn 0531 88382201 Section 1

Elimination 王克芳 wangkf@sdu. edu. cn 0531 -88382201 山�大学�理学院

Section 1 Urinary Elimination v Anatomy and Physiology v Assessment of Urination v Nursing Interventions for Urination v Nursing Skills for Urination 护理学基础 WKF SON SDU 2

Anatomy and Physiology Kidneys Ureters Urine formation v Hormone production v v v Diameter: 1. 25 cm Length: 20 to 30 cm Bladder --Hollow, distensible, muscular organ v Organ of excretion v Reservoir of urine Urethra F： 4 -5 cm， 短、直、粗 Internal sphincter v External sphincter : voluntary v M: 18 -20 cm 3个狭窄 2个弯曲

Act of Urination 护理学基础 WKF SON SDU 4

Act of Urination volume 400 -500 ml bladder stretch sensor spinal cord micturition center （brain stem, cerebral cortex） Desire to void Pelvic nerve micturition center （S 2 -S 4） parasympathetic impulses Pelvic nerve detrusor muscle contract internal urethral sphincter relaxing external urethral sphincter relaxing Voding--Emptying bladder

Problems v Ignore the urge v External sphincter remains contracted v Eventually, bladder capacity is maximum v Pressure on sphincter makes voluntary control impossible v Neurogenic bladder v Spinal cord injury above sacral region v v Loss of voluntary control of urination: incontinence Sacral region injury v Retention v Blockage v Retention 护理学基础 WKF SON SDU 7

Assessment of Urination v Normal Patterns v Altered Urinary Elimination v Factors Affecting Urination 护理学基础 WKF SON SDU 8

Normal Patterns Times v Amounts v Color Clarity Specific gravity p. H Odor v 护理学基础 WKF SON SDU 9

Normal Patterns Times: 3 -5 at daytime v 0 -1 at night v v Amounts: 200 -400 ml/time v 1000 -2000 ml/24 hr v 护理学基础 WKF SON SDU 10

Normal Patterns v Color v Pale, straw to deep yellow – normal v v Dark red v v Bleeding from kidneys or ureters Bright red v v More concentrated in morning Bleeding from bladder or urethra Dark amber v High levels bilirubin v Liver dysfunction 护理学基础 WKF SON SDU 11

Normal Patterns v Clarity v v v Transparent when fresh – normal Foamy--Kidney disease Thick and cloudy--Bacteria v Specific gravity v 1. 015 -1. 025 v Higher v v Concentrated urine: Dehydration, reduced renal blood flow, increased ADH Lower v Dilute urine: Overhydration, early renal disease, inadequate ADH 护理学基础 WKF SON SDU 12

Normal Patterns v p. H 4. 5 -7. 5 average: 6. 0 v Indicates acid base balance v v Odor Slightly aromatic (fresh) – normal v Ammonia --Stagnant v Sweet or fruity v Diabetes v Starvation v 护理学基础 WKF SON SDU 13

Altered Urinary Elimination v Oliguria（少尿）, Anuria（无尿）, Polyuria（多尿） v Frequency（尿频）, Urgency（尿急）, Dysuria（尿痛） v Urinary Incontinence（尿失禁） v Retention of urine（尿潴留） 护理学基础 WKF SON SDU 14

Oliguria <400 ml/24 hr Dehydration Renal failure Increased ADH Anuria Polyuria <100 ml/24 hr >2500 ml/24 hr Severe shock Excess fluid intake Diabetes Diuretics Acute renal failure

膀胱刺激征 (Bladder Irritation Syndrome ) Frequency--Urination at more frequent intervals Increased fluid intake v Bladder inflammation v Increased pressure on bladder v Urgent micturition --A sudden strong desire to urinate Full bladder v Urinary tract inflection v Psychological stress v Dysuria--Difficult or painful urination Bladder inflammation v Trauma v Inflammation of urethra v

Urinary Retention(尿潴留) v Definition: v Holding urine in the bladder and can’t excrete voluntary v 尿液大量存留于膀胱内而不能自行排出 v Causes v Urethral obstruction v Trauma v Altered motor and sensory innervation of bladder v Medication side effects v anxiety 护理学基础 WKF SON SDU 17

Urinary Incontinence Definition v International Continence Society (ICS) ： Condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable v 客观存在的不自主性尿液排出，并对社会活动和个 人卫生造成不良影响。 护理学基础 WKF SON SDU 18

Categories of Incontinence v 压力性尿失禁（Stress Incontinence） v 充溢性尿失禁（Overflow Incontinence） v 急迫性尿失禁（Urge Incontinence） v 功能性尿失禁（Functional Incontinence） 护理学基础 WKF SON SDU 19

Stress Incontinence v Occurs with increase in abdominal pressure v coughing, straining, sneezing, lifting heavy objects, etc. v The most common type in women, mid-aged, elderly v A result of weakened pelvic muscles v A malfunction of the urethral sphincter Childbirth v Lack of estrogen v Pelvic surgery v Obesity v 护理学基础 WKF SON SDU 20

Urge Incontinence v Abrupt desire to void which cannot be suppressed v Common in women and the elderly v Causes: The majority of cases are idiopathic Infection, tumor, stones, urethritis, stroke, Parkinson’s Disease, dementia �所 --那么近 --却那么� 护理学基础 WKF SON SDU 21

Overflow Incontinence The uncontrollable leakage of small amount of urine from a overfilled and enlarged bladder v Bladder outlet obstruction v v BPH, fecal impaction Non-contractile bladder v diabetes, spinal injury, medications 护理学基础 WKF SON SDU 22

Functional Incontinence v mental or physical disabilities to control urinating, the urinary system itself is normal. v Conditions that can lead to functional incontinence : v Parkinson's disease v dementia v v Mental confusion may prevent both recognition of the need to void and locating a bathroom. Severe depression 护理学基础 WKF SON SDU 23

Factors Affecting Urination v Fluid Intake v Age v Health Status and treatment v Emotional Status v Others 护理学基础 WKF SON SDU 24

Fluid Intake v Fluid Homeostasis Input = output v Caffeine promotes urine formation v Alcohol inhibits ADH v Fever causes diaphoresis v 护理学基础 WKF SON SDU 25

Age v Young v Control of urination begins between 2 to 3 years of age v Nighttime : cannot control till age 4 or 5 v Elderly Mobility problems v Chronic neurological problems v Changes in kidney and bladder function v 护理学基础 WKF SON SDU 26

Health Status Diseases v Peripheral nerve lesions v Loss of bladder tone v Reduced sensation v Difficulty in control v Physical disability v Difficult to reach/use toilet 护理学基础 WKF SON SDU 27

Health Status Surgery v Stress of surgery v Triggers General Adaptation Syndrome v v Increased ADH Elevated aldosterone v Anesthetic analgesics Slows glomerular filtration rate v Impairs sensory and motor impulses v v Lower abdominal and pelvic area surgery v Edema and inflammation 护理学基础 WKF SON SDU 28

Health Status Medications v Prevent reabsorption v Diuretics v Urinary retention v v v Anticholinergics Antihistamines Antihypertensives v Color change v Toxic to kidneys 护理学基础 WKF SON SDU 29

Emotional Status v Anxiety v Stress Urgency v Frequency v Muscle tension v v Difficult to relax abdominal and perineal muscles 护理学基础 WKF SON SDU 30

Other factors v Social cultural norms Privacy environment v Facilities v v Habits v Proper positioning v Climate 护理学基础 WKF SON SDU 31

Nursing interventions for urination v Urinary Retention v Urinary Incontinence 护理学基础 WKF SON SDU 32

Interventions for Urinary Retention patient Privacy environment Squatting for female Normal position Standing for male Sensory stimuli Running water Hand in water Warm the bedpan Muscle relaxing Health education habits ：time voiding 耻骨上膀胱区� 敷或�灸 Medications 灌肠/排便诱导排尿 Catheterization 护理学基础 WKF SON SDU 33

Interventions for Urinary incontinence patient Maintain skin integrity, promote comfort External drain the urine Restore normal micturition Offer fluid: 2000 -3000 ml/day Bladder Retraining: Take to bathroom q 1 -2 H Pelvic floor muscle training, PFMT(Kegel's ) Catheterization Psychological support 收缩与放松盆底肌群 开始各持续 2秒，重复15次，Tid 每周增加 1秒收缩与放松时间，至 10秒 维持10秒，重复10次，Qd 护理学基础 WKF SON SDU 34

Nursing skills for urination Catheterization v Plastic, rubber or silica gel tube through urethra into bladder v Continuous flow of urine v Assess hourly urine output v Medication therapy 护理学基础 WKF SON SDU 35

Catheterization Types v Intermittent Catheterization v Insert long enough to drain bladder v v Repeat PRN Indwelling Catheterization Stays in place v Change periodically v 护理学基础 WKF SON SDU 36

Indications v Intermittent v urinary retention--Relieve bladder distention v Indwelling v Obstruction v Surgery （pelvic area、 Urinary system） v Obtain urinary specimen v Assess residual v Measure I&O in critically ill v Long term management of spinal cord injury v Urinary incontinence and Severe retention v Terminally ill with trouble moving 护理学基础 WKF SON SDU 37

Care and Removal v Care---Maintain flow and prevent infection v v v Sterile Maintain closed system Hang lower than bladder Clean with soap and water at least Qd v Area and tube v After each BM (bowel movement) Maintain fluid intake v Removal of indwelling catheter v v v Promote normal bladder function Prevent trauma Need order--Explain, empty, remove 护理学基础 WKF SON SDU 38

Nursing skills for urination Nursing Implications to Urine Tests v All specimens must be labeled with name, date and time of collection v Transported in time v If unable, refrigerate v Wear gloves 护理学基础 WKF SON SDU 39

Common Urine Tests Clean, not sterile v Random Don’t contaminate with stool Specific gravity; p. H; v Midstream Glucose Catheterized Culture and sensitivity v Timed Test renal function and urine composition 12 or 24 hours Creatinine clearance, protein 护理学基础 WKF SON SDU 40

Words v v v v v Urinary Elimination Kidney Ureter Bladder Urethra Oliguria Anuria Polyuria Frequency urination Urge urination v v v v v Dysuria Stress Incontinence Overflow Incontinence Urge Incontinence Functional Incontinence Retention of urine Intermittent Catheterization Indwelling Catheterization Bladder Irrigation 护理学基础 WKF SON SDU 41