Urinary Elimination Problems and Nursing Implications

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urinary retention
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An accumulation of urine due to the inability of the bladder to empty. Patient may void small amounts or urine frequently with no real relief. Discomfort is significant.
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Urinary incontinence
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Involuntary leakage of urine; can be temporary or permanent; can affect patients of any age, but is prevalent in elderly. Causes include problems w/movement and dressing, mental incapacity. Types include: Stress, urge, overactive bladder, overflow (leak r/t full bladder)
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Urinary diversion
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Diversion of urine from kidneys to external source (urinary stoma). May be necessary because of trauma, cancer, radiation, fistula, or chronic cystitis.
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Urinary Tract Infection (UTI)
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May result from catheterization or procedure; usually caused by bacteria E. coli, Women are more susceptible due to short urethra and close proximity to anus, s/s= dysuria, frequency, hematuria, Irritated bladder is known as cystitis and can cause hematuria, If infection spreads to the kidneys, pyelonephritis occurs, with symptoms of flank pain, tenderness, fever, and chills.
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Disease Conditions affecting Urine Elimination: Diseases affecting renal function
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change in volume or quality, the act of urination, or both.
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Disease Conditions affecting Urine Elimination: Conditions of the lower urinary tract,
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such as narrowing of urethra, altered innervation of bladder, weakened pelvic or perineal muscles
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Disease Conditions affecting Urine Elimination: Diabetes and neuromuscular diseases such as
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MS which change nerve function and cause possible loss of bladder tone, reduced sensation, and inability to inhibit bladder contractions
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Benign prostatic hyperplasia BPH
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in older men, may lead to urinary retention or incontinence.
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congitive impairment Alzheimer’s
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loss of ability to sense full bladder or to recall voiding procedure
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Diseases that slow or hinder
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physical activity
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conditions that make it difficult to
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reach and use toilet facilities
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End-stage renal disease
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uremic syndrome
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Medical interventions affecting urination: Surgical procedures
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Restriction of fluid intake lowers urine output. Stress causes fluid retention by increase of ADH Antidiuretic hormone causing water resorption and increasing aldostone causing retention of sodium and water. Surgery of lower abdomen and pelvic organs may impair urination because of trauma to surrounding tissues. After surgery involving ureters, bladder, urethra, patients often have foley catheters.
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Medical interventions affecting urination: Medications
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Some cause urinary retention and /or overflow incontinence. Some cause urgency and incontinence. Some change the color of urine: phenazopyridine to orange.
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Diagnostic examinations:
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Direct visualization: cystoscopy causes localized trauma and edema; afterward, patients may have difficulty voiding or may have red/pink urine.
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Symptoms related to urinary disturbances Include:
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Frequency, urgency , dysuria, polyuria, oliguria, hematuria, incontinence, and difficulty in starting the urinary stream. Dyruria is burning with urination. Nocturia is when an patient is awakening to void one or more times at night. Polyuria is when their is an excessive output of urine, Oliguria is when there is a decreased urinary output in spite of adequate fluid intake. Hematuria is blood in urine. Anuria is when the kidneys produce no urine. Diuresis is increased urine formation.
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Physical Assessment:
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Gather nursing history for patient’s urination pattern; symptoms and factors affecting urination.
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Conduct physical assessment of patient’s body systems potentially affected by urinary change:
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Skin an mucosa: Assess hydration by looking at turgor and texture. Kidneys: Flank pain may occur with infection or inflammation. Bladder: distended bladder rises about symphysis pubis. Gentle palpation on a distended bladder causes tenderness, pain, or urge to urinate. Urethral meatus: Observe for discharge, inflammation, and lesions.
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Assess characteristics of urine
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odor, color, cloudiness etc.
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Assess patient’s perception of urinary problems
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as it affects self-concept and sexuality.
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Physical Assessment:
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Gather relevant laboratory and diagnostic test data.
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Assessment of Urine: Intake and output from World Health Org.
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Normal output for adults: at least 0.5 ml/kg/hour. Normal output for children: at least 1 ml/kg/hour. Normal output for infants: at least 1-2 ml/kg/hour.
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Characteristics of urine: Color
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Pale-straw to amber color May be more concentrated in the morning Medications and some foods can change color
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Characteristics of urine: Clarity
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Transparent unless pathology is present.
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Characteristics of urine: Odor
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Ammonia in nature; ketones may be sweet fruity Dibetes Mellitus or starvation or diet.
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Characteristics of urine: Urine testing
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Specimen collection- can be random, clean, sterile, timed, midstream.
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Urine tests and diagnostic examinations: Urinalysis
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Renal Function tests include: BUN- blood, urea, nitrogen. Creatinine, Creatinine Clearance, Specific gravity. weight or concentration of substance compared with equal volume of water.
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Urine tests and diagnostic examinations: Culture
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Requires sterile, catheter or clean-catch sample.
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Noninvasive procedures:
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KUB, x-ray of kidney, ureters, bladder. CT, ultra sound, IVP pyyelogram.
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Invasive procedures:
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cystoscopy, direct visualization of bladder. uroscopy, visualization of ureters/urethra with or without biopsy.
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Nursing Diagnosis and Planning
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Social isolation, Disturbed body image, pain, urinary incontinence functional stress urge overflow, Risk for infection, Toileting self-care deficit, Impaired skin integrity, Impaired urinary elimination.
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Implementation: Health promotion Primary Prevention:
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Adequate hydration, empty bladder with first urge, no smoking, increased risk for bladder cancer, limit caffeine diuretic effect.
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Stimulating micturition reflex helps patient sense urge to urinate and control urethral sphincter.
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Females are better able to void in sitting or squatting position on bedpan or bedside commode. Promote complete bladder emptying by encouraging patients to attempt to double void after urine flow stops. Promote relaxation, including sensory stimuli, sound of running water, or pouring warm water over perineum.
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Implementation: Acute Care: Maintain elimination habits:
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allow time to void and provide privacy, give patients at least 30 minutes to provide a specimen.
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Implementation: Acute Care: Medications that help with incontinence or retention. For incontinence:
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Parasympathetic stimulation of the bladder detrusor muscle aids emptying. Drugs that block receptors of this muscle suppress these contractions and reduce incontinence.
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Implementation: Acute Care: Medications that help with incontinence or retention. For retention:
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Cholinergic drugs increase bladder contraction and improve emptying.
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Catheteriazation:
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Provides continuous flow of urine.
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Implemention: Restorative Care. For stress or urge incontinence and for difficulty starting and stopping urination:
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Strengthening pelvic floor muscles. Kegel exercises.
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bladder retraining:
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toilet on schedule, if able slowly increase times between voiding, keeps bladder from getting full and less dribbling.
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Habit training:
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helps patients improve voluntary control over urination. Patient establishes flexible toileting schedule based on their pattern.
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Self-catheterization:
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For patients with chronic disorder such as spinal cord injury. Learn self-catheterization.
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Maintence of skin integrity
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clean, dry to prevent breakdown. Promotion of comfort.
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Implementation: Older Adults. Provide frequent opportunities to void.
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Older adults have a smaller bladder capacity than younger adults.
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Encourage older adults to empty the bladder completely
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before and after meals and at bedtime.
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encourage patients to increase fluid intake to at least
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six to eight glasses a day unless medically contraindicated.
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Cranberry juice and Vitamin C
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help acidify urine to decrease bacterial infections of the bladder.
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Restricting fluid intake does not
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decrease urinary incontinence severity or frequency
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incontinence is not a normal part of aging.
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Important to assess and provide interventions to promote continence.
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avoid routine use of indwelling catheter
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increases risk of infection.
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Managing urinary retention: Introduction of sterile tube into bladder
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Straight catheter, indwelling catheter: foley. or a Suprapubic catheter.
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Catheters may be:
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teflon coated, silicone, latex silastic.
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Larger number is larger lumen
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14-16 french for women, 16-18 french for men, 8-10 french for child. 2-way catheter has 2 lumens. 3-way has 3 lumens One lumen is for irrigation of fluid.
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Collection of Specimens: Urine collection. Clean catch:
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clean perineum 3 times females front to back before voiding, collect midstream urine in sterile cup. Refrigerate if not tested within 2 hours.
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Collection of Specimens: Urine collection. Sterile:
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straight cath or foley cath in bladder. Mark specimen as sterile catch.
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Collection of Specimens: Urine collection. 24-hour specimen
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Have patient void and record time, collect all voidings time 24 hours. If voiding is missed. Start again.
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Urine collection in children
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Specimen collection from infants and children is often difficult, offer fluids at least 30 minutes before requesting specimen.
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Use terms for urination the child can understand.
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such as pee, tinkle, pee-pee.
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Adolescents and school-aged children usually are able to cooperate.
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Use a brown paper bag to disguise specimen.
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Preschool children and toddlers have difficulty voiding on request.
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A potty chair or specimen hat place under the toilet seat is usually effective.
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Use special collection devices for infants and toddlers
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clear plastic bag over child’s urethral meatus.
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Do not squeeze urine from diaper to obtain sample
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Test results will not be accurate.

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