P&P CH 46: URINARY ELIMINATION

P&P CH 46: URINARY ELIMINATION

1. FACTORS THAT COMMONLY IMPACT URINARY ELIMINATION

   • GROWTH & DEVELOPMENT
     • OLDER ADULTS: -may experience a decrease in bladder capacity, increased bladder irritability, and increase frequency of bladder contractions during bladder filling. -the ability to hold urine between the initial desire to void and an urgent need to void decreases -are at increased risk for urinary incontinence because of chronic illnesses and factors that interfere with mobility, cognition, and manual dexterity
     • SOCIOCULTURAL FACTORS
       • -gender and cultural norms vary -religious or cultural norms may dictate who is acceptable to help with elimination practices -social expectations
       • PSYCHOLOGICAL FACTORS
         • -anxiety & stress -depression can decrease the desire to go
         • PERSONAL HABITS
           • -the need for privacy -adequate tie to void
           • FLUID INTAKE
             • If fluids, electrolytes, and solutes are balanced, increased fluid intake increases urine production -alcohol decreases the release of antidiuretic hormones, thus increasing urine production
             • PATHOLOGICAL CONDITIONS
               • -diabetes, multiple sclerosis, and stroke alter bladder contractility. Pts either experience overactivity or deficient bladder emptying -arthritis, Parkinson's disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet -spinal cord injury or intervetebral disk disease
               • SURGICAL PROCEDURES
                 • MEDICATIONS
                   • -diuretics -some medications change the color of the urine -anticholinergic may increase the risk for urinary retention by inhibiting bladder contractility -hypnotics and sedative may reduce the ability to recognize and act on the urge to void
                   • DIAGNOSTIC EXAMS
                     • Cytoscopy can cause trauma to the urethra

2. COMMON ALTERATIONS ASSOCIATED WITH URINARY ELIMINATION

   • URINARY RETENTION
     • THE INABILITY TO PARTIALLY OR COMPLETELY EMPTY THE BLADDER
     • UTI
       • CAUTI
         • CATHETER-ASSOCIATED UTI
         • URINARY INCONTINENCE
           • URINARY DIVERSION
             • PTs THAT HAD THEIR BLADDER REMOVED AND DIVERTED URINE TO THE OUTSIDE OF THE BODY THROUGH AN OPENING IN THE ABDOMINAL WALL CALLED A STOMA.

3. OBTAINING A NURSING HISTORY FROM A PT WITH AN ALTERATION IN UE

   • PATTERN OF URINATION
     • INCLUDES: -FREQUENCY -TIME OF DAY -NORMAL VOLUME AT EACH VOIDING
     • SYMPTOMS OF URINARY ALTERATIONS
       • INCLUDES: -URGENCY -DYSURIA -FREQUENCY -HESITANCY -POLYURIA -OLIGURIA -NOCTURIA -DRIBBLING -HEMATURIA -RETENTION
       • ASSESSMENT OF FACTORS THAT ARE AFFECTING THE ABILITY TO URINATE NORMALLY

4. PHYSICAL ASSESSMENT FOCUSED ON UE

   • KIDNEYS
     • ASSESS FOR TENDERNESS BY GENTLY PERCUSSING THE COSTOVETEBRAL ANGLE (THE ANGLE FORMED BY THE SPINE AND TWELFTH RIB)
     • BLADDER
       • EXTERNAL GENITALIA
         • PERINEAL SKIN

5. NORMAL URINE

   • PALE STRAW COLOR TO AMBER
     • APPEARS TRANSPARANT
       • NORMAL PNEUOMONIA SMELL

6. ABNORMAL URINE

   • HEMATURIA
     • BRIGHT RED, DARK RED
       • FOUL ODOR

7. NURSING IMPLICATIONS OF COMMON DIAGNOSTIC TESTS

   • RANDOM (ROUTINE ANALYSIS)
     • COLLECT DURING NORMAL VOIDING OR FROM AN INDWELLING CATHETER OR URINARY DIVERSION COLLECTION BAG
     • USED FOR SCREENING AND DIAGNOSTIC FOR FLUID AND ELECTROLYTE DISTURBANCES, UTI, PRESENCE OF BLOOD AND OTHER METABOLIC PROBLEMS
     • CLEAN-VOIDED OR MIDSTREAM (CULTURE AND SENSITIVITY)
       • URINE MAY BE COLLECTED BY THE PATIENT AFTER DETAILED INSTRUCTION ON PROPER CLEANSING AND COLLECTION TECHNIQUE ALWAYS USE A STERILE SPECIMEN CUP
       • STERILE SPECIMEN FOR CULTURE AND SENSITIVITY
         • PT WITH INDWELLING CATHETER, COLLECT A SPECIMEN BY USING STERILE ASPETIC TECHNIQUE THROUGH THE SPECIAL SAMPLING PORT FOUND ON THE SIDE OF THE CATHETER. NEVER COLLECT SPECIMEN FROM THE DRAINAGE BAG
         • DETERMINES THE PRESENCE OF BACTERIA AND TO WHICH ANTIBIOTIC THE BACTERIA ARE PRESENCE
         • TIMED URINE SPECIMENS
           • REQUIRES URINE COLLECTION AND TESTING EITHER AT SPECIFIC TIME OF DAY OR URINE COLLECTED OVER A SPECIFIC TIMED PERIOD
           • TIMED PERIOD BEGINS AFTER THE PT URINATES AND ENDS WITH A FINAL VOIDING AT THE END OF THE TIME PERIOD. IN MOST 24-HOUR SPECIMEN COLLECTIONS DISCARD THE FIRST VOIDED SPECIMEN AND THEN STARTED COLLECTING TIME
           • DEPENDING ON THE TEST, THE URINE CONTAINER MAY NEED TO BE EKPT COOL BY SETTING IT IN A CONTAINER OF ICE. EACH SPECIMEN MUST BE FREE OF FECES AND TOILET TISSUE. MISSED SPECIMENS MAKE THE WHOLE COLLECTION INACCURATE.

8. NURSING DIAGNOSES ASSOCIATED WITH ALTERATIONS

   • ph 4.6 TO 8.0
     • pH LEVEL INDICATES ACID-BASE BALANCE. ACID pH HELPS PROTECT AGAINST BACTERIAL GROWTH. URINE THAT STANDS FOR SEVERAL HOURS BECOMES ALKALINE FROM BACTERIAL GROWTH
     • PROTEIN (UP TO 8mg/100mL)
       • PROTEIN IS NORMALLY NOT PRESENT IN URINE. THE PRESENCE OF PROTEIN IS A VERY SENSITIVE INDICATOR OF KIDNEY FUNCTION
       • GLUCOSE
         • NOT NORMALLY PRESENT WITH POORLY CONTROLLED DIABETES HAVE GLUCOSE IN THE URINE BECAUSE OF INABILITY OF TUBULES TO REABSORB HIGH SERUM GLUCOSE CONCENTRATION
         • KETONES
           • NOT NORMALLY PRESENT WITH POORLY CONTROLLED DIABETES, PT EXPERIENCES BREAKDOWN OF FATTY ACIDS. END PRODUCT OF FATTY ACID METABOLISM ARE KETONES. PT WITH DEHYDRATION, STARVATION, OR EXCESSIVE ASPIRIN INGESTION ALSO HAVE KETONURIA
           • BLOOD
             • A + TEST FOR OCCULT BLOOD OCCURS WHEN INTACT ERYTHROCYTES, HEMOGLOBIN, OR MYOGLOBIN IS PRESENT. DAMAGE TO THE GLOMERULUS OR TUBULES CAUSE BLOOD CELLS TO ENTER URINE. TRAUMA OR DISEASE OF THE LOWER URINARY TRACT ALSO CAUSE HEMATURIA
             • SPECIFIC GRAVITY (1.0053 TO 1.030)
               • MEASURES CONCENTRATION OF PARTICLES IN URINE HIGH SPECIFIC GRAVITY=CONCENTRATED URINE LOW SPECIFIC GRAVITY=DILUTED URINE
               • MIRCOSCOPIC EXAM RBC (UPT TO 2)
                 • WBCs (0-4 PER LOW-POWER FIELD)
                   • ELEVATED #S INDICATED INFLAMMATION AND INFECTION
                   • BACTERIA (NOT NORMALLY PRESENT)
                     • BACTERIA IN THE URINE CAN MEAN INFECTION OR COLONIZATION
                     • CASTS
                       • CYLINDRICAL BODIES NOT NORMALLY PRESENT, THE SHAPES OF WHICH TAKE ON THE LIKENESS OF OBJECTS WITH THE RENAL TUBULE TYPES INCLUDE HYALINE, WBCs, RBCs, GRANDULAR CELLS, AND EPITHELIAL CELLS. THEIR PRESENCE INDICATE RENAL DISEASE
                       • CRYSTALS (NOT NORMALLY PRESENT)
                         • CRYSTALS INDICATE INCREASED RISK FOR THE DEVELOPMENT OF RENAL CALCULI (STONE). PTs WITH HIGH URIC ACID LEVELS (GOUT) MAY DEVELOP URIC ACID CRYSTALS

9. NURSING MEASURES TO PROMOTE NORMAL MICTURITION AND IMPROVE BLADDER CONTROL

   • MAINTAINING ELIMINATION HABITS
     • MAINTAINING ADEQUATE FLUID INTAKE

10. NURSING MEASURES TO REDUCE RISK FOR UTI

    • PT IN ACUTE CARE HOSPITAL SHOULD HAVE URINARY CATHETERS INSERTED USING ASEPTIC TECHNIQUE WITH STERILE EQUIPMENT
      • SECURE INDWELLING CATHETERS TO PREVENT MOVEMENT AND PULLING ON THE CATHETER
        • MAINTAIN A CLOSED URINARY DRAINAGE SYSTEM
          • KEEP URINARY DRAINAGE BAG BELOW THE LEVEL OF THE BLADDER AT ALL TIMES
            • EMPTY DRAINAGE BAG WHEN HALF FULL
              • PERFORM ROUTINE PERINEAL HYGIENE DAILY AND AFTER SOILING USING ANTISEPTIC WIPES. BE SURE TO USE A WIPE TO CLEAN THE LENGTH OFT HE EXPOSED CATHETER