Urinary Elimination

Dian Adiningsih

A & P Review

Physiology of Urinary Elimination

Kidneys

The paired kidneys are situated on either side of the spinal column, behind the peritoneal cavity. They are the primary regulators of fluid and acid base balance in the body. The functional units of the kidneys, the nephrons, filter the blood and remove metabolic wastes. In the average adult 1.200 mL of blood, or about 21% of the cardiac output, passes through the kidneys every minute.

Glomerulus

A tuft of capillaries surrounded by Bowmans capsule

Glomerular filtration are made up of water, electrolytes, glucose, amino acids, metabolic wastes .

From Bowmans capsule filtrate moves into tubule of the nephrons Proximal convoluted tubule

Most of water, electrolytes are reabsorbed.

Solutes such as glucose are reabsorbed in the loop of Henle in distal convoluted tubule Additional water, sodium are reabsorbed under the control of hormones , e.g ADH , aldosterone

If fluid intake or the concentration of solutes in the blood is high ADH is released , more water is reabsorbed in the distal tubule, less urine is excreted Fluid intake , concentration of solutes in the blood is low ADH is suppressed. Aldosterone is released from the adrenal cortex, sodium, water are reabsorbed in greater quantities blood volume, U.O.

Ureters
- The ureters are from 25 to 30cm long in the adult and about 1.25cm in diameter. - At the junction between the ureters and the bladder, a flap like fold of mucous membrane acts as a valve to prevent reflux (backflow)of urine up the ureters.

Bladder

Urinary bladder is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. In men, the bladder lies in front of the rectum and above the prostate gland In women it lies in front of the uterus and vagina. The wall of the bladder is made up of four layers
a.
b. c. d.

an inner mucous layer connective tissue layer three layers of smooth muscle fibers an outer serous layer. The smooth muscle layers are collectively called the detrusor muscle . The detrusor muscle allows the bladder to expand as it fills with urine, and to contract to release urine to the outside of the body during voiding.

Normal bladder capacity is between 300 and 600 ml of urine.

Urethra

The urethra extends from the bladder to the urinary meatus In the adult women, the urethra lies directly behind the symphysis pubis, anterior to the vagina, and is between 3 and 4cm long. The urethra serves only as a passage way for the elimination of urine. In the male, the urethra is approximately 20 cm long and serves as a passageway for semen as well as urine. In both men and women, the urethra has a mucous membrane lining that is continuous with the bladder and the ureters. Thus an infection of the urethra can extend through the urinary tract to the kidneys.

Pelvic Floor
The vagina and the urethra and rectum pass through the pelvic floor which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis. The internal sphincter muscle situated in the proximal urethra and the bladder neck is composed of smooth muscle under involuntary control. The external sphincter muscle is composed of skeletal muscle under voluntary control, allowing the individual to choose when urine is eliminated.

Urination

Micturition, voiding, urination all refer to the process of emptying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors

This occurs when the adult bladder contains between 250-500 ml of urine Children bladder contains between 50-200 ml of urine, stimulates these nerves.

Stretch receptors transmit impulses to the spinal cord Voiding reflex center located at the level of the 2nd to 4th sacral vertebrae causing Internal sphincter to relax Stimulation to void If the time and the place are appropriate for urination, conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place.

Factors Affecting Voiding

Developmental factors
Infants

Unable to concentrate urine b/c kidneys are immature During the first year, U.O gradually increases according to fluid intake to 250 500 ml / a day. Infant may urinate as often as 20 times a day Characteristic of urine

colorlessodorless, specific gravity of 1.008

Urine control between ages 2 and 5 years.

Developmental factors
Preschoolers The preschooler is able to take responsibility for independent toileting. Parent need to realize that accidents do occur and the child should never be punished. School age children The kidneys double in size between ages 5 and 10 years. During this period the elimination system reaches maturity.

Developmental factors

Enuresis, Involuntary passing of urine when control should be established (about 5 years of ages) Nocturnal enuresis or bed wetting is involuntary passing of urine during sleep Bed wetting should not be considered a problem until after the age of 6.

Developmental factors
The nocturnal enuresis can be divided into Primary enuresis : When the child has never achieved night time urinary control. Secondary enuresis : Related to another physical problem and resolves when the cause is eliminated. Causes: stress, illness.

Developmental factors
Adult 1500 1600 mls urine/24hrs Concentrates urine normal is amber colored Nocturia

Not usually Decreased renal blood flow during rest Ability to concentrate urine

Developmental factors
Elders Excretory function of the kidney diminishes with age, but not less than normal unless a disease is occur. With age, the number of functioning nephrons decreases to some degree, impairing the kidneys filtering abilities. Bladder muscle tone diminishes, causing increased frequency of urination and nocturia ( awakening to urinate at night). Diminished bladder muscle tone and contractibility may lead to residual urine in the bladder after voiding, increasing the risk of bacterial growth and infection.

Psychological factors
A set of conditions helps stimulate the micturition reflex include privacy normal position sufficient time running water sometimes the clients accustomed conditions may produce anxiety and muscle tension also some people may voluntarily suppress urination because of time pressure, for example nurses often ignore the urge to void until they are able to take a break.

Fluid and food intake

The healthy body maintains a balance between the amount of fluid ingested and the amount of fluid eliminated if fluid intake , the output . Certain fluids, e.g alcohol, fluid output by inhibiting ADH production. Fluid that contain caffeine (e.g coffee, tea, cola) urine production. Foods and fluids high in sodium can cause fluid retention. Some foods and fluids can change the color of urine. Beets can cause urine to appear red. Carotene can cause the urine to appear yellow than food containing usual.

Medications

Many medications affecting the autonomic nervous system interfere with the normal urination process and may cause retention

Diuretics (e.g chlorothiazide, furosemide) urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into blood stream.

Muscle tone

Good muscle tone is important to maintain the stretch and contractility of the detrusor muscle so the bladder can fill adequately and empty completely.

Pathologic conditions

Diseases of the kidneys may affect the ability of the nephrons to produce urine . Heart and circulatory disorders such as heart failure, shock hypertension can affect blood flow to the kidneys, interfering with urine production. Abnormal amounts of fluid loss (vomiting or high fever). Water is retained by the kidneys and urinary output falls. A urinary stone may obstruct a ureters , blocking urine flow from the kidney to the bladder. Hyper trophy of the prostate gland may obstruct the urethra impairing urination and bladder emptying.

Surgical and diagnostic procedures

May affect the passage of urine and the urine itself Cystoscopy, surgical procedures, spinal anesthetics.

Altered Urine Production

Abnormalities Polyuria: Large volume of urine Oliguria: Decreased amt (100-400ml/24hr) Anuria: No urine output (<100ml/24hr)

Polyuria ( diuresis )
Production of abnormally large amounts of urine by the kidneys,often several liters more than the clients usual daily output. Causes: Excessive fluid intake (polydipsia). Associated with diabetes mellitus. Diabetes insipidus. Chronic nephritis.

Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, Weight loss.

Oliguria and Anuria

Oliguria is low urine output, usually less than 500 ml a day or 30 ml an hour for an adult. Anuria refers to lack of urine production. Causes: Lack of fluid intake. Impaired blood flow to the kidneys. Renal failure.

Altered urinary elimination

Abnormalities Nocturia: Frequent urination at night Urgency : Is the sudden strong desire to void Dysuria: Painful or difficult urination Hesitancy: Difficulty in initiating voiding Hematuria: Blood in the urine

Frequency and Nocturia

Urinary frequency is voiding at frequent intervals, that is, more often than 4 to 6 times per day. Causes: UTI. Stress. Pregnancy can cause frequent voiding of small quantities (50 to 100 ml) of urine. Nocturia is voiding two or more times at night.

Urgency
Is the sudden strong desire to void. Causes: Psychological stress and irritation of the trigone and urethra. Common in young children who have poor external sphincter control and unstable bladder contractions.

Dysuria
Voiding that is either painful or difficult. Causes UTI. Injury to the bladder and urethra. Often Urinary hesitancy (a delay and difficulty in initiating voiding) is associated with dysuria.

Enuresis
Involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age .Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. Diurnal (day time) enuresis may be persistent and pathologic in origin .It affects women and girls.

Urinary incontinence
Or involuntary urination is a symptom not a disease. Clients at highest risk for developing incontinence include those with: A history of UTI. Surgery. Trauma. STD. Multiply vaginal births. Musculoskeletal. Endocrine. Neurological disorders.

It have a significant impact on the clients life , creating physical problems such as skin breakdown and possible leading to psychosocial problems such as embarrassment , isolation , social withdrawal .

Urinary retention
Is impaired in the emptying of the bladder, urine accumulates and the bladder becomes over distended. Causes : Prostatic hypertrophy (enlargement). Surgery. Some medication. The client may experience over flow voiding or incontinence eliminating 25 to 50 ml of urine at frequent intervals.

Neurogenic bladder
Impaired neurologic function can interfere with the normal mechanism of urine elimination .The client with a neurogenic bladder does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic with frequent involuntary urination.

Nursing Management

Assessing
Nursing

history. Physical assessment - Percussion of the kidneys to detect areas of tenderness - Palpation and percussion of the bladder. - Inspection of the urethral meatus of both male and female for swelling, discharge, and inflammation.

Nursing history.
Assessing urine

- Normal urine consists of 96% water and 4% solutes. Organic solutes include urea, ammonia, creatinine and uric acid. Inorganic solutes include sodium chloride, potassium sulfate, magnesium and phosphorus.

Assess Urine Intake and output (amount measured in cubic centimeters-cc) Characteristics - color, clarity, odor Urine Testing Urinalysis; random urinalysis Clean-void, mid-stream, sterile collection timed urine-12 -24 hour test

Urine Testing (contd.) Specific Gravity Urine Culture sterile; via urinary catheter port

Specimen Collection in Children

Measuring urinary output Avg. volume per voiding:200ml 250ml Normal Output per 24 hours: 1500ml Color: yellow, light to darker Clarity: clear Odor: NH4 Voiding without discomfort Measuring residual urine Residual urine (urine remaining in the bladder following the voiding) is normally 50 to 100 ml.

Diagnostic tests

Blood tests [urea, creatinine] used to evaluate renal function.

Urea, end product of protein metabolism is measured as BUN. Creatinine is product in relatively constant quantities by the muscles.

Creatinine clearance test

Uses 24 hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function.

Noninvasive Abdominal X-rays KUB (kidney, ureter, and bladder) flat plate of abdomen IVP (Intravenous Pyelogram) Renal Scan CT Scans-computerized axial tomography Renal or Bladder Ultrasound

Invasive Endoscopy

Arteriogram Urodynamic

Diagnosing
NANDA includes one general diagnostic label for urinary elimination problems and several labels that are more specific. - Impaired urinary elimination - Risk for infection
Etiology:Urinary retention Invasive procedure (catheterization or Cystoscopy)

- Low self esteem or social isolation

Etiology:Urinary incontinence

- Risk for impaired skin integrity

Etiology:Urinary incontinence

- Risk for social isolation: if the client is incontinent. - Disturbed body image: if the client has a urinary diversion ostomy

Implementing
Maintaining normal urinary elimination which include Promoting adequate fluid intake by:
fluid intake urine production A normal daily intake 1500ml fluids Client who are risk for UTI, urinary calculi ( stones) should consume 2000 to 3000ml of fluids daily .

Maintaining normal voiding habits

Assisting with toileting Assist the clients to the bathroom and remain with them if they are risk for falling Provides urinary equipment (urinal, bedpan, and commode).

Preventing urinary tract infections. Rate of UTI in women is about 20% in men 0.1%. Most common causes of UTI is bacteria (E. coli). Instructions provided for the client to reduce the occurrence of UTI: Drink 8 glasses of water/ day. Practice frequent voiding every (2 to 4 hours). Void immediately after intercourse. Avoid use of harsh soaps, bubble bath, and powder.

Avoid tight fitting pants. Wear cotton rather than nylon under clothes. Girls and women should always wipe the perineal area from front to back. The acidity of urine through regular intake of vitamin C.

Managing Urinary Incontinence

Continence (Bladder) Training A bladder training program may include the following: The client post pone voiding Resist or inhibit the sensation of urgency Void according to a time table rather than according to the urge to void voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours Practice deep, slow breathing until the urge diminishes or disappears this inhibiting the urge to void sensation.

Pelvic muscle exercises (PME) or Kegel exercises help to: Strengthen pelvic floor muscles and can reduce or eliminate episodes of incontinence. The client can identify the perineal muscles by stopping urination mid stream or by tightening the anal sphincter.

Urinary Catheterization

Urinary catheterization is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine. Catheter; is the tube for injecting or removing fluids Catheterization considered the most common cause of nosocomial infections that is infection acquired in hospital

Types of catheters

Retention catheter or Foley catheter; is a catheter that remain in place for continuous drainage Straight catheter or intermittent are used to drain the bladder for shorter periods from 5-10 minutes patients can be taught for straight catheter Supra-pubic catheter; used for continuous drainage this type of catheter is surgically inserted through a small incision above the pubic area

Reasons for catheterization: To relieve urinary retention To obtain a sterile urine specimen especially in women To measure the amount of urine To empty the bladder during or after surgery and before certain diagnostic examination Hazards of catheterization: 1) Infection 2) Trauma

3) Sepsis

Nursing Intervention for clients with indwelling catheters

1. Fluid The client with a retention catheter should drink up to 3,000 ml per day if permitted. 2. Dietary measures Acidifying the urine of clients may reduce the risk of urinary tract infection and calculus formation. Foods such as eggs, cheese, meat, tomatoes tend to increase the acidity of the urine. Unlike the fruits and vegetables, milk and milk products result in alkaline urine 3. Perineal care 4. Changing the catheter and tubing

Urinary irrigations

Is a flushing or washing out with a specified solution usually to wash out the bladder and some times to apply a medication to the bladder lining The closed method of catheter or bladder irrigation a three- way, or triple lumen catheter used for closed irrigations Open method of catheter irrigations performed with double- lumen indwelling catheters.

Urinary Diversions

Is the surgical rerouting of urine from the kidneys to a site other than the bladder. Urinary diversion created when the bladder must be removed for example cancer, trauma.

There are types of diversions 1. Incontinent 2. Continent

1. Incontinent Clients have no control over the passage of urine and require the use of an external ostomy appliance to contain the urine. Examples of incontinent diversions include: Ureterostomy Is when one or both of the ureters may be brought directly to the side of the abdomen to form small stomas.

Nephrostomy Diverts urine from the kidney to a stoma

Vesicostomy

Bladder is left intact but voiding through the urethra is not possible (e.g. obstruction, neurogenic bladder). The ureters remain connected to the bladder, and the bladder wall is sutured to the abdominal wall, forming an incontinent stoma.

ileal conduit ( ileal loop )

A segment of the ileum is removed and the intestinal ends are reattached One end of the portion removed is closed with sutures to create a pouch, and the other end is brought out through the abdominal wall to create a stoma The ureters are implanted into the ileal pouch

2. Continent This mechanism giving clients control over the passage of urine.

Examples of continent diversions include: Kock pouch or continent ileal bladder conduit Neobladder