Fundamental Nursing Chapter 30 Urinary Elimination n The

Fundamental Nursing Chapter 30 Urinary Elimination

n The urinary system (Fig. 30 -1) consists of the kidneys, ureters, bladder, and urethra. These major components, along with some accessory structures such as the ring-shaped muscles called the internal and external sphincters, work together to produce urine (fluid within the bladder), collect it, and excrete it from the body. 2

Figure 30 -1 • Major structures of the urinary system. 3

n Urinary elimination (the process of releasing excess fluid and metabolic wastes), or urination, occurs when urine is excreted. Under normal conditions, the average person eliminates approximately 1500 to 3000 m. L of urine each day. The consequences of impaired urinary elimination can be life-threatening. 4

n The need to urinate becomes apparent when the bladder distends with approximately 150 to 300 m. L of urine. The distention with urine causes increased fluid pressure, stimulating stretch receptors in the bladder wall and creating a desire to empty it of urine. 5

Patterns of urinary elimination depend on n physiologic n emotional, n social factors. n degree of neuromuscular development n and integrity of the spinal cord; n the volume of fluid intake and n the amount of fluid losses, n the amount and type of food consumed; n the person's circadian rhythm, n habits, n opportunities for urination, n and anxiety. 6

General measures to promote urination include: providing privacy, n assuming a natural position for urination (sitting for women, standing for men), n maintaining an adequate fluid intake, and n using stimuli such as running water from a tap to initiate voiding. n 7

Characteristics of Urine 8

Urine Specimen Collection Voided Specimens n A voided specimen is a sample of fresh urine collected in a clean container. The first voided specimen of the day is preferred because it is most likely to contain substantial urinary components that have accumulated during the night. 9

Clean-Catch Specimens A clean-catch specimen is a voided sample of urine considered sterile and is sometimes called a mid-stream specimen because of how it is collected. n As soon as the specimen is collected, it is labeled and taken to the laboratory. n 10

Catheter Specimens n A urine specimen can be collected under sterile conditions using a catheter, the nurse can aspirate a sample through the lumen of a latex catheter or from a self-sealing port (Fig. 30 -2). 11

Figure 30 -2 • Location for collecting a catheter specimen. 12

24 -Hour Specimens n The nurse collects, labels, and delivers a 24 hour specimen (collection of all urine produced in a full 24 -hour period) to the laboratory for analysis. 13

Abnormal Urine Characteristics Hematuria: urine containing blood n Pyuria: urine containing pus n Proteinuria: urine containing plasma proteins n Albuminuria: urine containing albumin, a plasma protein n Glycosuria: urine containing glucose n Ketonuria: urine containing ketones n 14

Abnormal Urinary Elimination Patterns n Anuria n n Anuria means absence of urine or a volume of 100 m. L or less in 24 hours. It indicates that the kidneys are not forming sufficient urine. Oliguria, urine output less than 400 m. L per 24 hours, indicates inadequate elimination of urine. n Residual urine, or more than 50 m. L of urine that remains in the bladder after voiding n 15

n Polyuria means greater than normal urinary volume and may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e. g. , coffee, tea), or taking certain medications actually can increase urination. 16

n Nocturia n n Nocturia (nighttime urination) is unusual because the rate of urine production is normally reduced at night. Dysuria n Dysuria is difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. Frequency (need to urinate often) and urgency (strong feeling that urine must be eliminated quickly) often accompany dysuria. 17

n Incontinence means the inability to control either urinary or bowel elimination and is abnormal after a person is toilet-trained. 18

Assisting Clients with Urinary Elimination n Commode n A commode (chair with an opening in the seat under which a receptacle is placed) is located beside or near the bed (Fig. 30 -3). 19

Figure 30 -3 • A bedside commode 20

n Urinal n A urinal is a cylindrical container for collecting urine. It is more easily used by males. 21

n Using a Bedpan n A bedpan (seatlike container for elimination) is used to collect urine or stool. Figure 30 -5 • Two types of bedpans: fracture pan) left (and conventional bedpan) right. ( 22

Catheterization n Catheterization (act of applying or inserting a hollow tube), A urinary catheter is used for various reasons: Keeping incontinent clients dry (catheterization is a last resort that is used only when all other continence measures have been exhausted) n Relieving bladder distention when clients cannot void n 23

n Assessing fluid balance accurately n Keeping the bladder from becoming distended during procedures such as surgery n Measuring the residual urine n Obtaining sterile urine specimens n Instilling medication within the bladder 24

Types of Catheters n External Catheters n An external catheter (urine-collecting device applied to the skin) is not inserted within the bladder; instead, it surrounds the urinary meatus. Examples of external catheters are a condom catheter (Fig. 30 -7) External catheters are more effective for male clients. 25

Figure 30 -7 • A condom catheter is an example of an external urine collection device. 26

n Straight Catheters n n A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen (Fig. 30 -9). Retention Catheters n A retention catheter, also called an indwelling catheter, is left in place for a period of time (see Fig. 30 -9). The most common type is a Foley catheter. 27

Figure 30 -9 • Types of urinary catheters A (Retention (Foley) catheter with balloon). B (Straight catheter. 28

n Unlike straight catheters, retention catheters are secured with a balloon that is inflated once the distal tip is within the bladder. Both straight and retention catheters are available in various diameters, sized according to the French scale: for adults, sizes 14, 16, and 18 F are commonly used. 29

Inserting a Catheter 30

Providing Catheter Care n “Catheters left in place for more than a few weeks become encrusted or obstructed, and lead to infection. In addition, bacteria that adhere to the urinary catheter develop a complex biologic structure, which protects them from antibiotics” 31

n Catheter care (hygiene measures used to keep the meatus and adjacent area of the catheter clean) helps to prevent the growth and spread of colonizing pathogens. 32

Figure 30 -11 • Techniques for suspending a drainage system below the bladder) : A (wheelchair patient) ; B (ambulating patient with and without an IV pole. 33

Continuous Irrigation A continuous irrigation (ongoing instillation of solution) instills irrigating solution into a catheter by gravity over a period of days (Fig. 30 -12). n Continuous irrigations keep a catheter patent after prostate or other urologic surgery in which blood clots and tissue debris collect within the bladder. n 34

Figure 30 -12 • Bladder irrigation using a three-way catheter 35

Urinary Diversions In a urinary diversion, one or both ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. The ureters may be brought to and through the skin of the abdomen. A urostomy (urinary diversion that discharges urine from an opening on the abdomen), or implanted within the bowel (called an ileal conduit) (Fig. 30 -14). n SPC n 36

Figure 30 -14 • Examples of urinary diversions). A (Ileal conduit). B (Cutaneous ureterostomy 37

Nursing Implications n n n n n Self-Care Deficit: Toileting Impaired Urinary Elimination Risk for Infection Stress Urinary Incontinence Urge Urinary Incontinence Reflex Urinary Incontinence Total Urinary Incontinence Functional Urinary Incontinence Situational Low Self-Esteem Risk for Impaired Skin Integrity 38