Neurological System

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Chapter 22

Urinary Function

Bladder capacity decreases, prevalence of involuntary bladder contractions increases, and more urine is produced at night.

Women: declining estrogen levels, thinning and increased friability of urethral mucosa, and altered pelvic floor muscle tone and function cause urgency and frequency

Men: prevalence of prostatic hypertrophy increases, resulting in incontinence or urinary retention

Age-Related Changes in Structure and Function

UI is common in older adults and is associated with irritant dermatitis, pressure injuries, falls, significant sleep interruptions, and UTIs.

Many health care providers do not ask patients about incontinence, even when patients inform them about incontinence and therefore it is not diagnosed or treated.

Urinary Incontinence (UI)

Acute incontinence: sudden onset, generally associated with some medical or surgical condition, generally resolves when underlying cause has been corrected

Drugs are a common cause.

Chronic incontinence: not related to an acute illness, continues over time, often becoming worse

Five major types include: urge, stress, overflow, functional, and mixed incontinence

Incontinence

Most common type, may be associated with overactive bladder

Causes: urinary tract infection (UTI), medications, bladder irritants, bowel issues, dementia, stroke, Parkinson’s disease, and cancers of the uterus and urinary system

Involuntary urine loss after sudden urge to void

Can be precipitated by sound of running water, cold weather, or sight of toilet

Often accompanied by nocturia and complaints of frequency

Urge Incontinence

Commonly seen in older women who involuntarily lose urine as result of sudden increase in intraabdominal pressure

Caused by lack of estrogen, obesity, previous vaginal deliveries, surgeries

Leak urine with physical exertion: coughing, sneezing, laughing, lifting, and exercise

Unusual in men, and mainly occurs after transurethral surgery or radiation therapy

Stress Incontinence

Chronically full bladder increases bladder pressure to level higher than urethral resistance, causing the involuntary loss of urine

Common in men

Complain of constant dribbling

Causes: urethral blockage, weakened bladder muscles, nerve injury or damage, constipation, or drugs

Overflow Incontinence

Caused by physical, mental, psychologic, or environmental factors interfering with the ability to make it to the toilet on time

Not recognizing the need, lack of motivation or physical barrier to the toilet

Functional incontinence should be a diagnosis of exclusion.

Functional Incontinence

Combination of two or more other types: stress, urge, overflow, or functional incontinence

Community-dwelling older adults: mixed urge and stress incontinence common

Residential facilities: urge and functional incontinence is most common

Mixed Incontinence

Which of the following are examples of overflow incontinence? (Select all that apply.)

Patient is depressed and does not participate in anything.

Patient has to urinate every time he or she hears water running.

Older adult man has BPH.

Laughing cause urine to leak out.

Patient had a nerve injury after a car accident.

Patient has acute UTI.

Nursing assistant left the walker out of the patient's reach.

Lifting a heavy object results in leaking.

Quick Quiz!

ANS: C, E

Answer to Quick Quiz

Basic evaluation for UI: history, physical examination, postvoid residual testing, and urinalysis

Major cases of incontinence can be cured or significantly improved if treatable factors contributing to incontinence are identified and appropriate medical and nursing interventions are implemented.

Diagnosis of UI

Assess the patient’s incontinence symptoms and bladder habits, general health and medical problems, current drugs, and past medical, surgical, and obstetric histories

Ask men about prostate surgery or radiation.

Ask women about estrogen replacement.

Conduct the following assessments: functional, environmental, and psychosocial.

Conduct physical exam

Can you name four nursing diagnoses for UI?

UI: Assessment and Diagnosis

Stress urinary incontinence

Urge urinary incontinence

Overflow urinary incontinence

Functional urinary incontinence

The patient with stress and urge incontinence will:

Master interventions designed to increase pelvic muscle tone

Recognize factors that precipitate stress accidents and use behavioral interventions to prevent accidents

The patient with overflow incontinence will:

Seek urologic evaluation of incontinence

Master in-and-out self-catheterization (if has an atonic bladder)

The caregiver for the patient with functional incontinence will:

Provide timely assistance with toileting

Remove environmental barriers to proper toileting

UI: Planning and Expected Outcomes

Nursing interventions for UI focus on lifestyle modifications and behavioral therapies.

Pharmacologic options are for patients with urge or mixed incontinence who have failed a trial lasting up to 3 months of lifestyle and behavioral therapies.

UI: Intervention

Do not to decrease fluid intake to fewer than six glasses a day.

Eliminate or restrict caffeine intake.

Weight loss

Assess bowel habits for constipation.

Cognitively intact patients: bladder retraining and pelvic floor muscle exercises

Cognitive impaired patients: scheduled toileting, habit training, and prompted voiding

Lifestyle Modifications for UI

Patient goals are the focal point of evaluation.

Patient’s perception of effectiveness of and satisfaction with treatment should be assessed and documented.

UI: Evaluation

Kidneys decrease in size and number of nephrons as individuals age.

Decreases in renal mass, functioning glomeruli, and blood flow; affects GFR

Changes in renal function affect all aspects of pharmacokinetics.

Age-Related Renal Changes

Sudden decline in renal function with fluid and electrolyte alterations, and acid-base disturbance

May or may not be associated with oliguria

Classified as prerenal, intrarenal, or postrenal depending on the causative factor

Acute Kidney Injury (AKI)

Prerenal failure occurs because of inadequate perfusion.

Intrinsic failure occurs because of abnormalities within the kidney and may be caused by ischemia, sepsis, inflammation, or injury with acute tubular necrosis (ATN) as most common cause.

Postrenal failure caused by obstructive or mechanical process in the urinary tract that interferes with the outflow of urine.

Classifications of AKI

Diagnosis is based on an elevated blood urea nitrogen(BUN) level, an elevation in serum creatinine, and a decrease in creatinine clearance accompanied by a decrease in urine output.

Treatment includes correcting the underlying cause of AKI, correction of acidosis and hematologic abnormalities, removal of nephrotoxic agents, and maintenance of fluid hemostasis.

AKI Diagnosis and Treatment

Kidney damage for more than 3 months and decrease in GFR

Symptoms depend on the extent of the disease.

There are five stages of CKD:

stages 1–3 are asymptomatic.

Stages 4 and 5, patients may develop weakness, edema, fatigue, hypertension, heart failure, impaired cognition and immune function, dry skin and pruritus, anorexia, nausea, malnutrition, increased bleeding, anemia, peripheral neuropathy, and an overall decreased quality of life.

Chronic Kidney Disease (CKD)

Treat the underlying cause of CKD: aggressive control of blood pressure, treatment of hyperlipidemia, blood sugar control in diabetics, avoidance of nephrotoxic medications and use of ACEI and ARBs for individuals with proteinuria

Restricting sodium, potassium, protein, and phosphorus in the diet

Restricting fluid intake, weight management, and use of multivitamins and iron supplements

CKD Management

Health history and physical examination; special attention should be paid to medication history.

Can you name at least eight nursing diagnoses for CKD?

CKD: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Achieve a normal level of fluid volume use

Consume a well-balanced, appropriately restricted diet on a regular basis

Remain free from infection

Demonstrate knowledge of the disease process and therapeutic regimen

Demonstrate the use of effective coping strategies

CKD: Planning and Expected Outcomes (1 of 2)

The patient will do the following:

Demonstrate the ability to carry out ADLs without undue stress or fatigue

Maintain skin integrity

Have adequate cardiac output

Maintain hemoglobin above 10 g/dL

Express satisfaction with expression of intimacy

CKD: Planning and Expected Outcomes (2 of 2)

Focus on maintaining fluid and electrolyte balances; monitoring nephrotic symptoms

Educate about treatment regimens, diet management, and medication usage; and managing fatigue and low energy levels

CKD: Intervention

Subjective data: patient’s reported symptoms and quality of life

Objective data: improved or stable renal function as evidenced by stable levels of BUN and creatinine, hematocrit, and fluid and electrolytes

CKD: Evaluation

UTI and asymptomatic bacteriuria are common.

Incidence higher for residents of extended care or nursing facilities

Risk factors: brain attack, Parkinson’s disease, cognitive impairment and dementia, decreased functional status, bladder catheterization, and antibiotic use

Escherichia coli continue to be most common organism

Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and fluoroquinolone-resistant gram negative bacilli are becoming more prevalent.

Urinary Tract Infection (UTI)

Lower UTI: dysuria, urgency, frequency, and hematuria

Upper UTI: fever, chills, flank tenderness, and mental status changes

If patient has bacteremia signs and symptoms of septic shock may be seen.

UTI Clinical Presentation

Subjective assessment of urinary elimination patterns: normal voiding patterns and symptoms such as burning, urgency, and frequency

Mental status examination may be indicated.

Can you name three nursing diagnoses for UTI?

UTI: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience adequate pain control

Resume a normal voiding pattern, free from frequency, urgency, and dysuria

Verbalizes knowledge of the causes and treatment of UTI

UTI: Planning and Expected Outcomes

Educate on appropriate perihygiene measures, adequate daily fluid intake, adherence to prescribed medication regimen, and reportable signs and symptoms of recurrent infection

Ongoing assessment of expected outcomes

Documentation of achievement of expected outcomes and routine vital signs, assessment of functional status, and other associated risk factors

UTI: Intervention and Evaluation

Most common form of cancer originating in the urinary system

Most bladder tumors are easily resected but may metastasize to bladder wall, pelvis, liver, lungs, or bone.

Biggest risk factor is cigarette smoking; occupational exposure to dyes, rubber, chemicals used in processing leather, and paint also increases risk.

Bladder Cancer

Painless hematuria is the most common symptom.

May also be accompanied by dysuria, urgency, and frequency

If the tumor is large, late signs include suprapubic pain, and, may also cause post renal failure.

Bladder Cancer Clinical Manifestations

History with attention to changes in urinary elimination patterns

Subjective assessment should focus on the presence of pain, hematuria, dysuria, urgency, frequency, and voiding of small volumes.

Objective assessment findings include gross or microscopic hematuria.

Can you name five nursing diagnoses for bladder cancer?

Bladder Cancer: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience reduced anxiety

Develop a routine for managing urinary diversion

Verbalize acceptance of urinary diversion and associated changes

Demonstrate the use of effective coping strategies

Verbalize sexual concerns

Express satisfaction with alternative positions for intercourse

Bladder Cancer: Planning and Expected Outcomes

Provide education, psychosocial support, pain management, and maintain adequate fluid and nutritional intake.

Educate regarding management of urinary diversion devices.

Encourage verbalization of fears and concerns.

For chemotherapy: monitor for UTIs, irritative voiding symptoms, allergic reactions, and bone marrow suppression

Bladder Cancer: Intervention

Evaluation of nursing interventions based on achievement of expected outcomes

Document ongoing biopsychosocial assessment

Bladder Cancer: Evaluation

Age-related enlargement of prostate gland that constricts urethra and obstructs outflow of urine

Is the result of structural, functional, and hormonal changes

As prostate enlarges symptoms include: hesitancy, decrease in force of urinary stream, terminal dribbling, sensation of full bladder after voiding, and urinary retention

Urethral obstruction may cause urinary stasis, UTIs, hydronephrosis, and renal calculi.

Benign Prostatic Hypertrophy (BPH)

Includes history and physical examination, digital rectal examination, and measurement of BUN and serum creatinine levels

Prostate-specific antigen (PSA) test may be ordered in some cases to rule out prostate cancer.

BPH Diagnostic Evaluation

Assessment consists of history, physical examination, and evaluation of voiding patterns.

Can you name four nursing diagnoses for BPH?

BPH: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Maintain a regular schedule of complete bladder emptying

Remain free from UTIs, as evidenced by the use of measures to prevent infection

Verbalize sexual concerns and describe measures to cope

Demonstrate an understanding of the evaluation and treatment of BPH

BPH: Planning and Expected Outcomes (1 of 2)

The postsurgical patient will do the following:

Have satisfactory pain control as indicated by 3 or less on 0–10 scale

Regain urinary control similar to that experienced in the premorbid state

BPH: Planning and Expected Outcomes (2 of 2)

Educate regarding diagnosis and management of disease and establishing of a frequent voiding schedule.

For patients treated with nonsurgical methods, focus on educating about signs and symptoms of progressive BPH and drugs used to relieve symptoms, their side effects, and drug interactions.

For surgical post-op patients, maintain patients’ levels of function, prevent postoperative complications related to immobility, and allow verbalization about temporary sexual dysfunction.

BPH: Intervention

Evaluate return of urinary function to premorbid state, relief of urinary symptoms, avoidance or prompt management of UTIs, and return to satisfactory sexual activity.

BPH: Evaluation

Increases with age; by age 90, 70% of men have some degree of prostate cancer.

Risk factors: advancing age, family history, and African American race

Early prostate cancer: typically asymptomatic

As tumor enlarges, may cause symptoms of urinary obstruction, may manifest symptoms of postrenal failure; other signs: perineal and rectal discomfort, weakness, nausea, hematuria, and lower extremity edema

Skeletal pain and pathologic fractures may indicate advanced disease with metastases.

Prostate Cancer

Essentially the same as that for a patient with BPH

Assess patient’s health beliefs and fears related to malignant process

Can you name four nursing diagnoses for prostate cancer?

Prostate Cancer: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Have their urinary elimination patterns return to the premorbid state

Resolve anxiety about the diagnosis, treatment, and prognosis and understand the prognosis

Will have a mutually satisfying sexual relationship

Demonstrate knowledge of treatment methods and prognostic indicators

Prostate Cancer: Planning and Expected Outcomes

Educate patient on diagnostic tests and treatment options.

Postsurgical: administer analgesics for pain control, suggest options for sexual counseling if needed, educate on the importance of a follow-up

Hormonal therapy: educate patient on administration of injections

Bone metastasis: encourage safety measures around the home to decrease incidence of pathologic fractures

Prostate Cancer: Intervention

Evaluation of interventions based on patient’s relief of symptoms from obstruction and return to premorbid urinary elimination pattern

Patient should verbalize an understanding of the disease process, staging of tumor, and recommended treatment.

Patient and partner should regain satisfactory sexual relations.

Prostate Cancer: Evaluation

The nurse is conducting a urinary assessment on a male patient. The nurse suspects the patient has BPH when which of the following is noted?

Dysuria

Terminal dribbling

Mental status changes

Fever and chills

Quick Quiz!

ANS: B

Answer to Quick Quiz