Ch 36-2: The Nursing Process for Urinary Elimination

Promoting fluid intake

-Adults with no disease-related fluid restrictions should drink eight to ten 8oz glasses daily -Daily intake of water keeps kidneys and urinary structures well flushed, waste products and potential harmful bacteria are removed

Assessing Physical Assessment Bladder

-Before palpating, ask last void time -Bedside bladder scanner --Calculates urine volume residing in bladder --Noninvasive and painless --No risk of infection --Patient should be supine

Urinary Functioning as the Etiology

-Caregiver Role Strain related to incontinence of a family member -Impaired Skin Integrity (Actual, Risk for) related to incontinence -Acute Pain related to bladder spasms, dysuria, urinary retention, cancer of the bladder, diagnostic procedures -Disturbed Body Image related to urinary diversion -Disturbed Sleep Pattern related to nocturia -Toileting Self-Care Deficit relate to confusion, etc.

The older adult may experience

-Decreased control over urination -Find it difficult to reach a toilet in time due to mobility problems -Many adult disposable undergarments are available but when used improperly can lead to skin breakdown and place the patient at risk for a UTI

Measuring urine output in patients who are incontinent

-Difficult to accurately measure -Measured in amount of times incontinent -Scheduled toileting --Can assist with specimen collection --Prevent incontinence

Patient Teaching

-Drink eight to ten 8oz glasses of water daily -Observe urine color, amount, odor, and frequency ---Report any sign of infection to health care provider Dry the perineal area after urination or defecation from the front to the back, or from urethra to rectum

Caring for an Incontinent Patient Treatment

-Noninvasive, low-risk behavioral interventions -Pharmacological -Mechanical

Behavioral Techniques

-Pelvic floor exercises: Kegel exercises to strengthen pelvic floor muscles and sphincter muscles. Kegel exercises can be done alone, with weighted cones, or with biofeedback. -Biofeedback: Measuring devices are used to help patient become aware of when pelvic floor muscles are contracting. -Electrical stimulation: Electrodes are placed in the vagina or rectum that then stimulate nearby muscles to contract. -Timed voiding or bladder training: May be used with biofeedback. Patient keeps track of when voiding and leaking occur to enable oneself to plan when to void, with increasing length of voiding intervals. Bladder training involves biofeedback and muscle training. Urgency control is addressed using distraction and relaxation techniques

The Nursing Process - Evaluating

-Produce a sufficient quantity of urine to maintain fluid, electrolyte, and acid-base balance -Empty the bladder completely at regular intervals without discomfort -Provide care for urinary diversion and know when to notify the primary care provider -Develop a plan to modify any factors that contribute to current urinary problems or that might impair urinary functioning in the future -Correct unhealthy urinary habits, such as delaying voiding, drinking insufficient fluids, or abusing diuretics

Measuring urine output in patients with an indwelling catheter

-Put on gloves -Calibrated measuring device beneath urine collection bag (each patient should have their own) -Drainage spout above container, open clamp -Reclamp, wipe the spout and replace in slot of drainage bag

Promoting Normal Urination Maintaining normal voiding habits

-Schedule -Urge to void -Privacy -Position -Hygiene

Caring for an Incontinent Patient

-Urinary incontinence, any involuntary leakage of urine, is widely underreported and underdiagnosed -Common chronic health problem -Many people self-manage for many years before seeking assistance from a health care provider -More prevalent in women and increases with age

Measuring urine output in patients who are continent

-Use appropriate urinary collection device according to patient -Pour urine into calibrated device -Examine at eye level on a flat surface -Discard urine or send specimen if required

Anuria:

24-hour urine output is less than 50 mL; synonyms are complete kidney shutdown or renal failure

Functional Urinary Incontinence

Altered environmental factors Sensory, cognitive, or mobility deficits

Postvoid residual (PVR)

Amount of urine remaining in the bladder after urination -Bladder scanner -PVR less than 50 mL indicates adequate bladder emptying -PVR greater than 150 mL guideline for catheterization --Residual volume associated with the development of UTIs

Treatment

Antibiotic regimen usually eradicates infections of the lower urinary tract, longer therapy is required for upper urinary tract infections

Assessing Nursing History

Any report of a problem with voiding should be explored further -Duration, severity, and precipitating factors -Patient's perception of the problem and the adequacy of the patient's self-care behaviors

Collecting urine specimens Routine urinalysis

Aseptic technique, void collected in urinal, bedpan or hat -Clean-catch or midstream specimen --Void small amount, then continue into sterile container Considered a sterile specimen

Urine Characteristics

Assess the patient's urine for color, odor, clarity and the presence of sediment -Specific gravity --Measurement of the density of the urine compared with the density of water Table 36-1 Characteristics of Urine

Nocturia:

Awakening at night to urinate

Carefully assess environmental factors for their impact on urinary incontinence Equipment to facilitate movement to a toilet

Cane, walker, wheelchair

Assessing

Collection of data about the patient's voiding patterns, habits, and difficulties and a history of current or past urinary problems Physical examination of the bladder, if indicated, and urethral meatus: assessment of skin integrity and hydration; and examination of urine Correlation of these findings with results diagnostic test and procedures for examining the urine and the urinary tract

Point-of-Care Urine Testing

Commercially prepared diagnostic kit -Used for detecting the presence of glucose, protein, bilirubin, bacteria, and blood

Total incontinence

Continuous and unpredictable loss of urine Surgery, trauma, physical malformation

Stress incontinence

Coughing, sneezing, laughing, or other physical activity

Polyuria:

Excessive output of urine (diuresis)

Recent changes in urinary elimination

Have you noticed any changes in your usual voiding patterns (frequency, amount, force of stream, difficulty, comfort)? Do you ever leak urine (e.g., on your way to the bathroom or when you sneeze or cough)? Do you ever notice that your undergarments are wet or damp?

Urinary Retention

High urethral pressure caused by weak detrusor Inhibition of reflex arc Strong sphincter Blockage

Usual patterns of urinary elimination

How often do you urinate (pass your water) during the day? Do you awaken at night to empty your bladder? How would you describe your urine?

Diagnosing

Identify human responses to alterations in urinary elimination that pose specific health problems for the patient and family

Frequency:

Increased incidence of voiding

Assessing Physical Assessment Urethral orifice

Inflammation, odor, or discharge -Females Slit-like opening below clitoris and above vaginal orifice -Males Tip of the penis, uncircumcised retract foreskin

Urinary incontinence:

Involuntary loss of urine

Aids to elimination

Is there anything you do that helps you to urinate?

Assessing Physical Assessment Skin integrity and hydration

Issues with urinary functioning may result in disturbances in hydration and excretion of body wastes -Perineal area --Problems with incontinence --Lead to incontinence associated dermatitis -Reddened, excoriated

Caring for Patients with Urinary Tract Infections Diagnostic evaluation

Laboratory findings can identify the presence of a UTI -A culture & sensitivity test (C&S) is positive if it shows at least 100,000 organisms per milliliter of urine -Lower counts may be significant if the patient has signs and symptoms of a UTI ---Dysuria, frequency, urgency, cloudy urine, foul odor

Caring for Patients with Urinary Tract Infections

Leading cause of morbidity and health care expenditure in persons of all ages UTIs leading cause of systemic infections in older adults Women predisposed shorter urethra, close proximity to vagina and rectum

Collecting urine specimens Sterile specimen

May be obtained by catheterizing the patient's bladder or by taking a specimen from an indwelling catheter already in place

Special Assessment Techniques

Measuring Urine Output -Important nursing responsibility -Gloves are required to prevent exposure to pathogenic microorganisms or blood that may be present in the urine -May be delegated to unlicensed personnel

Collecting urine specimens 24-hour urine specimens

Must collect the urine voided in a 24-hour period -Patient voids and is discarded and the 24 hours starts ---The laboratory will specify whether the specimen must be kept on ice or refrigerated

Implementing

Nursing interventions focus on maintaining and promoting normal urinary patterns, improving or controlling urinary incontinence, preventing problems associated with bladder catheterization, assisting with care of urinary diversions

Stress Urinary Incontinence

Overdistention between voiding Weak pelvic muscles and structural supports

Dysuria:

Painful or difficult urination

Measuring urine output in patients who are continent If strict intake and output is ordered for the patient

Patient should be taught the process Ambulatory patients can use a specimen hat or urinal in the bathroom

Glycosuria:

Presence of sugar in the urine

Proteinuria:

Protein in the urine; indication of kidney disease

Pyuria:

Pus in the urine; urine appears cloudy

Oliguria:

Scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400 mL

Impaired Urinary Elimination

Sensory motor impairment Urinary tract infection Anatomic obstruction

Those at greatest risk for UTI

Sexually active women Women who use diaphragms for contraception Postmenopausal women Those with indwelling catheters in place People with diabetes mellitus Older adults

Transient incontinence

Short-term due to illness, infection, or current treatment

Reflex incontinence

Spinal cord injuries, no sensation to void

Collecting urine specimens Sterile specimen Obtaining a specimen from an indwelling catheter

Sterile technique in that the urine is protected from contamination -Syringe, antiseptic swab, sterile specimen cup, nonsterile gloves --If your is not present in tube may need to be clamped (never more than 30 minutes)

Suppression:

Stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h

Urgency:

Strong desire to void

Present or past occurrence of voiding difficulties (nature of problem, onset, frequency, causes, severity, symptoms, intervention attempted, results)

Tell me about any problems you are having now when you urinate (urgency, pain or burning, difficulty starting or stopping stream, dribbling, incontinence). If there is a problem, describe what you feel like before you urinate and while you are urinating. Have you had any urinary problems in the past (any history of urinary tract infections, kidney or bladder disease or problems)? Do you use any type of absorbent pad or product to protect your clothes?

Presence of artificial orifices (normal routine, history of problems)

Tell me about your usual routine with your ileal conduit.

Outcome Identification and Planning

The client will.... -Produce urine output about equal to fluid intake -Maintain fluid and electrolyte balance -Empty the bladder completely at regular intervals -Report ease of voiding Maintain skin integrity

Assisting with toileting

Toilet Commode Bedpan and urinal

Caring for Patients with Urinary Tract Infections Can affect

Upper urinary tract -Kidneys and ureters - pyelonephritis Lower urinary tract - cystitis -Escherichia coli, bacteria commonly found in GI tract most common causal organism

Diagnosing Urinary functioning as the problem

Urinary functioning as the problem -Specific issues of urination Urinary functioning as the etiology -When difficult with urination or changes in normal voiding patterns affect other areas of human functioning

Functional incontinence

Urine loss caused by inability to reach the toilet

Diagnostic Procedures

Various diagnostic procedures can be performed to study the functioning of the urinary system Nurses are responsible for preparing the patient for the procedure and giving appropriate aftercare -Explaining the procedure helps reduce anxieties Common Diagnostic Procedures Used to Study the Urinary Tract Box 36-2

Strengthening muscle tone

Weakening of pelvic floor muscles common cause of urinary continence problems -Kegel exercises --Target the inner muscles that lie under and support the bladder -These muscles can actually be made larger by a regular routine of tightening and relaxing

Overflow incontinence

With chronic retention of urine, overflow of urine

Age-related changes

do affect urinary function, but urinary incontinence can be treated and individualized interventions can help the patient lead a normal life