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URINARY ELIMINATION

OBJECTIVES

Differentiate among the anatomic location and functions of the kidneys, ureters, bladder, and urethra.

Explain the physiologic events involved in the formation and passage of urine from glomerular filtration to voiding and factors that effect it.

Select significant subjective and objective data related to the urinary system that should be obtained from a patient.

Link the age-related changes of the urinary system to the differences in assessment findings.

Select appropriate techniques to use in the physical assessment of the urinary system.

Differentiate normal from abnormal findings of a physical assessment of the urinary system.

Describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the urinary system.

Differentiate the normal from abnormal findings of a urinalysis.

Embryology—the development of the kidney

The kidneys and the ears from the same mesenchymal tissue

The otorenal axis

Nephrotoxic drugs and ototoxc drugs

Mesenchyme is a type of connective tissue found mostly during embryonic development of bilateral animals (triploblasts). It is composed mainly of ground substance with few cells or fibers.

Embryologic development

Kidneys appear during the 3rd week of fetal development; By the 3rd month the fetus is excreting urine into the amniotic fluid; urine becomes the main component of amniotic fluid

Kidneys

Kidneys located in the retroperitoneal space between T12 and L3
Right lower than the left (Liver 2-3lbs)

Kidney size is NOT affected by body build

The kidneys grow at the same rate that the entire body grows, until age 25-26

The mean dimensions of the kidneys upon maturation are: length~12cm (~4.7 inches), width~6 cm (~2.4 inches) and thickness~ 3 cm (~1.2 inches).
The weight of one kidney averages about 120-150 g (4.5-5 oz).

Kidney size

Any decrease in size (atrophy) is not normal.

An enlarged kidney is normal only in cases when one kidney is removed

Most important non-invasive test for renal disease is a renal ultrasound, to determine renal size

-the remaining kidney enlarges to compensate for the functional absence of the first. (1869 Gustav Simon: performed the first successful removal of the human kidney)

The kidney…retroperitoneal space

Palpation? Can you palpate the kidney in an adult?

Not unless the kidney is HUGE…(tumor)

Polycystic kidney disease (PKD)

The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be palpable under normal circumstances.

document the assessment information is needed.

Read more: Kidney Conditions Forum - Kidney Size and Health...what are normal dimensions? What c http://ehealthforum.com/health/topic64914.html#ixzz1KLqFRmC5

Polycystic kidney disease

A little more history…

Gustav Simon, in 1869, performed the first successful removal of a human kidney, the patient survived and the remaining kidney “picked up the slack” so to speak

FACT: The healthy kidney can grow enough to handle 80% of the load that 2 kidneys used to handle

Urinary System

Kidneys and ureters

Bladder

Urethra

Female and Male Urinary Tracts

Ureters

10 – 12 inches (25 – 30 cm) and about 0.04 to 0.4 inches (1 – 10 cm) in diameter

Prevents Vesicoureteral reflux

Muscular layer of the ureter

-When the bladder fills, the distal end of the ureter closes to prevent urine from backing up into the kidney

-If this mechanism is not working properly bacteria can reflux into the ureters and up to the kidneys—vesicoureteral reflux

-Muscularis layer of the ureter propels urine via peristalsis to bladder—1 to 5 contractions per minute

Renal Calculi (Kidney stones)

PAIN!!!! PAIN!!! PAIN!!!

Incidence increases with age

Higher in Caucasians than African-Americans

Common during pregnancy (2nd and 3rd trimesters)

Pregnancy--progesterone slows down peristalsis

Renal Calculi (Kidney stones)

Does fluid intake make a difference?

YES

This approach increases urine flow rate and decreases the urine solute concentration—both mechanisms prevent kidney stones.

-In warmer climates, inadequate fluid intake causes dehydration, which increases the acidity of urine and stone formation. (Southeastern U.S.= hot=increased kidney stones)

This time-honored recommendation for reducing the risk of kidney stones is to take two or more liters of fluids per day. And, not just any fluids…

Renal Calculi (Kidney stones)

Fluid increases urine flow rate and decreases the urine solute concentration = prevent kidney stones

2 or more liters of fluids per day

And, not just any fluids…

-In warmer climates, inadequate fluid intake causes dehydration, which increases the acidity of urine and stone formation. (Southeastern U.S.= hot=increased kidney stones)

Fluids associated with
kidney stones

Soft drinks

Tea

Southeastern U.S.=lots of tea

Grapefruit juice

The good news…

Alcohol, especially wine, and coffee consumption have been negatively associated with kidney stones.

How do we remove stones??

Least invasive: Strain urine

Percutaneous lithotripsy

Bladder

Smooth muscle sac innervated by ANS

Serves as a reservoir for urine

Composed of three layers of muscle tissue called detrusor muscle

Sphincter guards opening between urinary bladder and urethra

Urinary Bladder

Bladder

Medium-full bladder holds about 1 pint (500 mL) of urine and measures 5 inches (12.5 cm) in length

Fully expanded, the bladder can hold 1 quart (1 L) or more and YES, it can burst

Newborns void 5-to 40 times a day

At 2 months a baby voids 400 mL (14 fl oz) per day

Adolescents and adults—1.5 quarts (1500 ml) per day

Act of Urination (Micturition, Voiding)

Process of emptying the bladder

Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra

Muscle of abdominal wall contracts slightly

Diaphragm lowers, micturition occurs

Involuntary act but control can be learned. Nerve centers in the brain and spinal cord. Develops after infancy

Autonomic Bladder: no longer control by the brain

Urination

Awareness of urination starts at about 15 months

Control of nighttime urination sometimes takes until age four

Girls vs. boys and potty training

Girl’s brain pathways develops faster

Urethra

Urethra conveys urine from bladder to exterior of body

WOMEN - 1.5 inches (4 cm)

MEN?

6-8 inches (15-20 cm)

Cystitis

Lower urinary tract infections

Risk Factors:

Women

Wiping from back to front

Sexually active women/not voiding after sex

Lack of estrogen

Diabetes, BPH

Patients with indwelling catheters

Signs of UTI: Hematuria and Dysuria

E.Coli and the rectum

The importance of estrogen and the maintenance of urinary tract health

Estrogen is responsible for maintaining the lining of the bladder and promoting it’s blood supply and nutrition

Postmenopausal- bladder lining becomes very thin and prone to irritation and infection (UTIs)

Low levels of estrogen are thought to have a role in recurrent infections by causing changes in the urinary tract that make it more vulnerable to infection. Estrogen is responsible for maintaining the lining of the bladder and promoting it’s blood supply and nutrition. As estrogen declines, the bladder lining becomes very thin and prone to irritation and infection. This condition can cause UTI’s, burning pain when urinating and difficulty in holding back urine.
The concentration of estrogen receptors in the urethral mucosa is similar to that of the vaginal mucosa. Estrogen deprivation will result in atrophic urethritis and sometimes urinary incontinence, and estrogen replacement therapy may reverse this trend.

Acute Uncomplicated Pyelonephritis

Organism travels from the bladder into the kidneys.

Common in young children, older adults, women of childbearing age

Fever, chills, severe flank pain, dysuria, urinary frequency, urinary urgency, pyuria, and usually bacteriuria, CVA tenderness

E. coli: Causative organism in 90% of community-acquired infections

CVA (Costovertebral angle) Tenderness

Find the CVA by assessing for the 12th rib and the spine….just below the 12th rib in between the spine is the angle.
Lay your non-dominate hand flat over the angle.
Make a fist with your dominate hand and firmly thump the fist onto the flat non-dominate hand.
Ask the patient if they felt tenderness or pain.

CVA Tenderness

Question

Which term describes a condition in which 24-hour urine output is less than 50 mL?

A. Dysuria

B. Glycosuria

C. Pyuria

D. Anuria/Oliguria

Geriatric Considerations

Effects of aging
Nocturia BPH (Benign Prostatic Hypertrophy)
Increased frequency
Urine retention and stasis
Voluntary control affected by physical problems

Factors Affecting
Micturition (Urination)

Developmental considerations

Food and fluid intake

Psychological variables

Activity and muscle tone

Pathologic conditions

Medications

Micturition- the action of urinating

Types of Urinary Incontinence

Transient: appears suddenly and lasts 6 months or less (confusion, acute illness)

Overflow: over distention and overflow of bladder

Stress Incontinence: coughing, laughing

Functional: caused by factors outside the urinary tract (inability to reach the BR)

Mixed: urine loss with features of two or more types of incontinence

Effects of Medications on Urine
Production and Elimination

Diuretics: prevent reabsorption of water and certain electrolytes in tubules

Cholinergic medications: stimulate contraction of detrusor muscle, producing urination

Analgesics and tranquilizers: suppress CNS, diminish effectiveness of neural reflex

Pyridum

Assessing a Problem With Voiding

Explore its duration, severity, and precipitating factors.(medications)

Note the patient’s perception of the problem.

Check the adequacy of the patient’s self-care behaviors.

Maintaining Normal Voiding Habits

Schedule

Urge to void

Privacy

Position

Hygiene

Kegal exercises: contraction and relaxation of the pubococcygeal muscle

Diseases Associated With Renal Problems

Congenital urinary tract abnormalities

Polycystic kidney disease

Urinary tract infection

Urinary calculi

Hypertension

Diabetes mellitus

Structures and Functions
of Urinary System

Kidneys

Blood supply

Renal artery arises from the aorta

Divides into smaller branches

Each forms an afferent arteriole

Afferent arteriole divides into a capillary network: the glomerulus

Blood flow to the kidneys, approximately 1200 mL/min, accounts for 20% to 25% of the cardiac output.
Blood reaches the kidneys via the renal artery, which arises from the aorta and enters the kidney through the hilus.
The renal artery divides into secondary branches and then into still smaller branches, each of which forms an afferent arteriole.
The afferent arteriole divides into a capillary network, the glomerulus, which is a tuft of up to 50 capillaries (see Fig. 45-3).

Structures and Functions
of Urinary System

Physiology of urine formation

Tubular function

Reabsorption

Proximal convoluted tubule: 80% of electrolytes

Loop of Henle: water

Descending loop: water, some sodium, urea, other solutes

Ascending loop: chloride, sodium

Secretion

Tubules and collecting ducts carry out the functions of reabsorption and secretion.
Reabsorption is the passage of a substance from the lumen of the tubules through the tubule cells and into the capillaries. This process involves both active and passive transport mechanisms.
Tubular secretion is the passage of a substance from the capillaries through the tubular cells into the lumen of the tubule.

Anti-diuretic hormone

ADH is produced by the hypothalamus and released from the posterior pituitary

Tells your kidneys how much water to conserve

Constantly regulates and balances the amount of water in your blood

It tells your kidneys how much water to conserve. ADH constantly regulates and balances the amount of water in your blood

Free water is regulated by ADH (anti-diuretic hormone)

Conservation of free water

Diurnal rhythm—kicks in around midnight with water conservation and reduced urination at night

NO ADH at night?  NOCTURIA

body has to minimize water loss to remain sufficiently hydrated at night

Anti-diuretic hormone

Beer and ETOH inhibit ADH

a 6-pack of beer before bedtime? urinating all night

And morphine increases ADH as well as tightens the urinary sphincter (urinary retention—problem after surgery in patients on PCA pumps or anyone receiving morphine)

Fluid and electrolyte and acid-base balance

Regulation of water,

Electrolytes: Sodium, chloride, potassium, and phosphorus

Excretion of excess urea and creatinine

Excretion of excess hydrogen ions

Now that you know what the kidney is supposed to do…

What do YOU do?

Accurate intake and output

Daily weights

Check for signs of fluid retention—peripheral edema, jugular vein distention

Blood pressure

Interpretation of lab tests

Measuring Urine Output

Ask the patient to void into a bedpan, urinal, or specimen container in bed or bathroom.

Pour urine into the appropriate measuring device.

Place the calibrated container on a flat surface and read at eye level.

Note amount of urine voided and record on the appropriate form.

Discard urine in the toilet unless specimen is needed.

Devices for Collecting and Measuring Urine

If the kidney fails…

Retention of water—edema, weight gain, HTN

Retention of urea (BUN) and creatinine (as measured by serum creatinine and creatinine clearance)

Retention of Na+ resulting in hypertension

Retention of K+ resulting in hyperkalemia and potentially life-threatening cardiac arrhythmias

Retention of phosphorus resulting in hyperphosphatemia

Retention of H+ ions—metabolic acidosis

Lab tests

BUN

Serum creatinine

Estimated glomerular filtration rate (GFR)

Blood urea nitrogen (BUN)

Urea is a commonly used marker for the diagnosis of renal failure/kidney injury; by-product of protein metabolism (not produced at a constant rate)

BUN (8-18 mg/dL)—reasons for an elevated BUN

decreased GFR

Increased tissue metabolism (burns, crush injuries, rhabdomyolysis)

increased load of urea for excretion from the diet (protein), dehydration

Serum creatinine

Creatinine is released from skeletal muscle at a relatively constant state, is freely filtered at the glomerulus, and is not reabsorbed or metabolized by the kidneys

Hence, it’s popularity for measuring the ability of the kidneys to filter; if the kidneys are not filtering properly creatinine will be retained and the serum creatinine will be increased

Normal reference range is 0.5 to 1.0 mg/dL*

A few caveats--serum creatinine

Can be influenced by age, gender, muscle mass, diet, concomitant diseases, & drugs (cimetidine/Tagamet increases creat cl)

Important notes…

The NIH Consensus recommends that patients with chronic kidney disease be referred to a renal team when the serum creatinine has increased to 1.5 mg/dL in the female and 2.0 mg/dL in the male

Most nephrologists report that patients are usually referred to a renal healthcare team when their serum creatinine level is 3-4 mg/dL or greater…earlier is better!

Creatinine and the estimated GFR

What is the glomerular filtration rate?

Based on how much creatinine is CLEARED into the toilet (also known as creatinine clearance)

Glomerular filtration rate (GFR) =

creatinine clearance result

Creatinine and GFR

Estimated GFR

Normal estimated GFR in young adults is 105-130 mL/min (women 105 mL/min, guys 125 mL/min)

a GFR of less than 60 mL/min represents a loss of more than half of normal kidney function

GFR decreases with age—the 1% rule

RENAL FUNCTION…

Glomerular filtration rate (GFR)—120-125 ml/min at age 25; decreases by ~1% per year;

HEALTHY 75-year-old (not taking into account weight, ethnicity, or gender) May have a GFR of 67mL/min

BUT, a GFR of 60-89 mL/min=mild renal insufficiency

a GFR of less than 60 mL/min/ represents a loss of more than half of normal kidney function

Major functions of the kidney

Fluid and electrolyte balance

Acid-base balance

Vitamin D and calcium metabolism

RBC production via the hormone erythropoietin

Maintain blood pressure via Renin-Angiotensin-Aldosterone System (RAAS)

Vitamin D metabolism

The kidney converts the vitamin D from the skin and diet to the active form of vitamin D (calcitriol)

Vitamin D is necessary for the absorption of calcium from the GI tract

Calcium and phosphorus must always be “in balance” in the blood

If the kidneys fail, phosphate is retained and results in hyperphosphatemia

RBC production and erythropoietin

Secretes erythropoietin to stimulate the bone marrow to produce RBCs

Failing kidneys DO NOT secrete erythropoietin

Earliest signs of declining renal function is the presence of anemia

Almost half of all stage 3 CKD, are anemic

Urinalysis

In addition to ultrasound, the urinalysis is the second part of the ‘non-invasive’ measurement of renal function

Checking for protein in the urine (and other components) is an essential part of the renal work-up

Urinalysis

Can tell you all sorts of interesting information

Glucose—transport maximum 180 mg/dL; over that amount = Glucosuria

Proteinuria—trace, 1+, 2+, 3+, 4+ (glomerular injury with higher numbers)

Urinalysis

Pink or brownish tinge—blood, bile salts, red beets

Bright yellow—riboflavin in multivitamins

Frothy—bile salts (blocked bile duct, liver disease); protein (large amounts, glomerular disease)

Ketones—fruity odor; diabetes, low carb diet, fasting or starvation

Urinalysis

Specific gravity—1.001-1.035; tests the ability of the kidneys to concentrate urine

More concentrated the higher the specific gravity.

Urine Specimens

Routine urinalysis

Clean-catch or midstream specimens

Specimens from indwelling catheter

24-hour urine specimen

Specimens from infants and children

Obtaining a urine specimen from an indwelling urinary catheter. (A) Use an antiseptic swab to clean the access port. (B) Attach syringe and aspirate urine into the syringe.

Non invasive/ External catheters

https://sageproducts.com/primafit-external-urine-management-system-for-females/

Non invasive/ External catheters

Reasons for Catheterization

Relieving urinary retention

Obtaining a sterile urine specimen

Obtaining a urine specimen when usual methods can’t be used

Emptying bladder before, during, or after surgery

Monitoring critically ill patients

Increasing comfort for terminally ill patients

Using the Nursing Process

Assessing data about voiding patterns, habits, past history of problems

Physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; and examination of the urine

Correlation of these findings with results of procedures and diagnostic tests

Bladder Scan

50 mL and less is normal

Between 50 and 100 mL still normal for elderly

>200 mL is abnormal

Assessing a Problem With Voiding

Explore its duration, severity, and precipitating factors.

Note the patient’s perception of the problem.

Check the adequacy of the patient’s self-care behaviors.

Nursing Diagnoses

Urinary functioning as the problem

Incontinence

Pattern alteration

Urinary retention

Urinary functioning as the etiology

Anxiety

Caregiver role strain

Risk for infection

Planned Patient Goals

Produce sufficient quantity of urine to maintain fluid, electrolyte, and acid–base balance.

Empty bladder completely at regular intervals without discomfort.

Provide care for urinary diversion and know when to notify physician.

Develop plan to modify factors contributing to current or future urinary problems.

Correct unhealthy urinary habits.

Promoting Normal Urination

Maintaining normal voiding habits

Promoting fluid intake

Strengthening muscle tone (Kegal’s)

Assisting with toileting

Easy access to bathroom

If nocturia keep path clear and visible

Maintaining Normal Voiding Habits

Schedule

Urge to void

Privacy

Position

Hygiene

A Suprapubic Catheter Positioned in the Bladder

Urinary diversion

A urinary diversion is done when the normal flow of urine is blocked or the bladder can't store urine

Most common reason used is for bladder cancer (entire bladder removed)

A urinary diversion may also be called a urinary tract diversion or bladder diversion

Location of an Ileal Conduit

Urinary diversion

Goal : Divert urine outside of the body when the bladder is removed

Surgical procedure, where a small urine reservoir is created from a segment of a bowel and is placed just under the abdominal wall.

This opening is called a stoma.

Patient Education for Urinary Diversion

Explain reason for diversion and rationale for treatment

Demonstrate effective self-care behaviors

Describe follow-up care and support resources

Report where supplies may be obtained in the community

Verbalize related fears and concerns

Demonstrate a positive body image

You don't need to have a bladder to live, but you do need to keep up a normal flow of urine from the body.

Question

True or false:

Diuretics cause increased urine production, resulting in the need for increased urination and possibly urge incontinence.

A. True

B. False

Question

True or false:

A urine specimen from a patient with an indwelling catheter should be obtained from the collection receptacle (bag).

A. True

B. False

Answer

Answer: B. False

Rationale: A urine specimen from a patient with an indwelling catheter should be obtained from the catheter itself.

Question

True or false

There are no interventions effective for preventing urinary incontinence.

A. True

B. False

QUESTIONS??