Promoting Urinary Elimination Chapter 29 Promoting Urinary Elimination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 29 Lesson 29.1 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Review the structure and functions of the urinary system. Determine abnormal appearance of a urine specimen. Describe three nursing measures to help patients urinate normally. Clinical Practice Assess a patient’s urinary status. Perform a urine dipstick test accurately. Teach a patient how to obtain a “clean-catch” (midstream) specimen. Assist patients with toileting. Insert an indwelling catheter using sterile technique. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Structure of the Urinary System Kidneys Two bean-shaped organs 6 cm wide x 12 cm long Located at level of L1 on either side of the spine Each kidney contains approximately 1 million nephrons Nephrons Inside each nephron is a glomerulus consisting of a cluster of capillaries surrounded by Bowman’s capsule and a system of tubules Nephrons are the working units of the kidney Ask students to convert centimeters to inches and draw the actual size of an adult kidney (2.5 cm = 1 inch). Ask a volunteer to draw the kidneys to scale on the board. Reinforce there are approximately 1 million nephrons in each kidney. Ask students to landmark the anterior and posterior position of the kidneys. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Structure of the Urinary System (cont’d) Ureters Hollow tubes that carry urine from the kidneys to the bladder Each ureter is 25 to 30 cm long Bladder Hollow muscular organ located in lower pelvis that stores urine Urethra Carries urine from bladder to meatus; flow controlled by urinary sphincter Meatus—conducts urine to outside the body Ask students to convert centimeters to inches (2.5 cm = 1 inch) and draw the actual length of an adult ureter. Review that the bladder is a sterile area, as well as its access and its vulnerability to infection. Location of the bladder behind the pubic bone. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-1: Structures of the urinary system Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-2: Tract of the male urethra Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Function of the Urinary System Kidneys Filter blood through the nephrons Metabolic waste and excess water are extracted Regulate electrolytes by excreting excess amounts and help with acid-base balance retaining hydrogen ions and bicarbonate Tubules secrete, excrete, or reabsorb electrolytes, water, and other substances Efficiency of kidney function promotes the circulation through the renal arteries and renal veins. Kidneys receive 20% to 25% of the circulating blood supply. The nephron is composed of three parts: proximal tubule, loop of Henle, distal tubule. Kidneys are involved with renin production that influences blood pressure. Filtrate collected into the distal tubules becomes urine. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Function of the Urinary System (cont’d) Kidneys manufacture approximately 1.5 L of urine in 24 hours Urine production related to various factors Ureters carry urine from kidneys to bladder Bladder stores urine and signals when it is full Bladder empties when 250 to 400 mL of urine is present (under voluntary control) Another rule of thumb: 1 mL of urine/kg/hour Usual urine output for adult: 30 to 70 mL per hour Ask students to convert mL to ounces. (30 mL = 1 ounce) If less than 30 mL, patient may be experiencing decreased tissue perfusion and/or decreased cardiac output. Ask the students to discuss how decreased tissue perfusion may be causing decreased urinary output. Urine is transported through the ureters by gravity and unidirectional peristaltic waves; there are no sphincters between the bladder and the ureters. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Function of the Urinary System (cont’d) Bladder can contain 1000 to 1800 mL of urine Average urine output is 1000 to 1500 mL per day Urethra carries urine from bladder sphincter to the meatus Internal sphincter relaxes with micturition (urinating reflex) The external sphincter is under voluntary control At least 600 mL of urine must be excreted per day to remove waste products The bladder is a smooth muscle controlled by the parasympathetic nervous system, making this a voluntary and learned activity. If there is spinal cord or pelvic nerve damage, voluntary bladder control may become impaired. The bladder will continue to fill but may become distended. Ask students to discuss bladder function and bladder care for the individual disabled by a spinal cord injury or a stroke. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Factors Interfering with Urinary Elimination Blockage of the ureters Stones Tumors in the abdominal cavity Trauma to the lower abdomen Disruption of the bladder by tumor or trauma Enlarged prostate Trauma to the urethra Infection of the urinary system Neurologic damage Ask the students to draw the internal anatomy and illustrate how each of the above can cause a blockage of the ureters. Ask the students to identify specific signs and symptoms of each blockage. Ask the students to list two assessment questions for each of the above. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Changes Occurring with Aging Decrease in the number of functioning nephrons Decrease in filtration rate Decreased bladder tone—nocturia Decreased bladder emptying, increased residual Enlargement of prostate—urethral obstruction Incontinence is not a normal part of aging   Ask the students to identify two healthy lifestyle interventions for each example to minimize the effect of aging on the urinary system. Discuss the incontinence products that are advertised on commercials. Specifically comment on the individuals portrayed, their surroundings, and how the product seems to be the “ideal solution” to the problem of incontinence. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Normal Urinary Elimination Infants void 5 to 40 times/day Preschool children may void every 2 hours Adults void 5 to 10 times per day Males void 300 to 500 mL Females void 250 mL Average output should be approximately 30 mL/hr Ask the class why babies void so frequently. Ask the class how voiding patterns for preschoolers may influence the day’s activities. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Factors Affecting Normal Urination Neurologic and muscle development Alterations in spinal cord integrity Fluid volume intake Fluid loss in perspiration Vomiting Diarrhea ADH secreted by the pituitary Antidiuretic hormone (ADH) influences fluid balance in all of these situations: ADH responds to changes in the fluid osmolality of the blood; ADH determines how much the tubules reabsorb or discharge. If fluid intake (by mouth, IV) is decreased (or lost through vomiting or diarrhea), ADH is released to increase the absorption of water. If fluid intake is increased, ADH is suppressed, allowing more urine formation (diuresis). Ask the students how they monitor ADH function by assessing the patient’s I&O and hydration status. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Characteristics of Normal Urine Color Straw-colored or amber Clarity Transparent or only slightly cloudy Odor Faintly like ammonia Specific gravity Normal range is 1.010 to 1.030 pH Slightly acid, ranging from 5.5 to 7.0 Remind students to always use barrier precautions when dealing with urine. Urine specific gravity is influenced by protein and glucose. Urine specific gravity is also influenced by the use of IV contrast used for imaging studies. pH: Compare with normal blood pH (7.35–7.45). pH: Indication of the kidney’s compensatory mechanism for acid-base balance of the blood. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Alterations in Urinary Elimination Patterns Anuria Less than 100 mL of urine output in 24 hours Dysuria Painful or difficult urination; may be from infection or trauma Incontinence Involuntary release of urine Ask the students if they have cared for patients with these symptoms. Review documentation. Several types of renal function tests are available to determine the cause of these symptoms; renal function tests are ordered by the physician to evaluate the cause and severity of changes in renal function. Many renal function test results will remain within normal limits until renal function decreases 50% or more. Often patient symptoms may indicate an ongoing problem that has been compensated for until the symptoms became apparent. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Alterations in Urinary Elimination Patterns (cont’d) Nocturia When a person has to get up more than twice in the night to void Oliguria Decreased urine output less than 400 mL in 24 hours Polyuria Excessive urination (>1500 mL in 24 hours) Common renal function tests include renal concentration, creatinine clearance, serum creatinine, and BUN Ask the students about the nurse’s role for patient care undergoing these tests: Ongoing patient assessment Documentation of symptoms Reporting changes in I&O, not just at the end of the shift but throughout the shift as needed Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Alterations in Urinary Elimination Patterns (cont’d) Cystitis Inflammation of the bladder May be caused by irritation of highly concentrated urine, pathogenic bacteria, injury, or instillation of an irritating substance Symptoms: frequency, urgency, dysuria, burning, malaise, foul-smelling urine, slight temperature elevation What bacteria are often responsible for cystitis? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Urinary Specimens Normal voided specimen Send to the laboratory within 5 to 10 minutes Urine standing more than 15 minutes changes characteristics Midstream (clean-catch) specimen Specimen from an indwelling catheter Sterile catheterized specimen 24-hour specimen Strained specimen Ask the students to identify the rationale for obtaining each of these specimens. Review the nurse’s role for obtaining urine specimens: Patient teaching Barrier precautions Sterile technique Timely collection Prompt transport to lab Monitoring and reporting results Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-3: Urine collection devices Discuss urine collection devices and how they can support patient comfort and assist with urination. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Abnormalities Found in Urine Glycosuria Glucose in the urine Proteinuria Protein in the urine Hematuria Blood in the urine Pyuria Pus in the urine Ketonuria Ketones in the urine Ask the students if they have cared for a patient with these types of symptoms or urinalysis report results; discuss the significance of each. Based on these results, imaging diagnostic studies may be ordered: Ultrasound KUB x-ray CAT and MRI for sectional images IVP; cystogram Renal angiography; pyelography Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment Patients should be assessed for: Usual pattern of elimination Incidences of incontinence, frequent urination Burning on urination Sense of urgency Times of day for elimination Total daily fluid intake Discuss with the students why documentation of each of these would be important assessment information. Assessment findings may determine the need for further diagnostic tests, specifically diagnostic endoscopy: Cystoscopy Renal biopsy Renal endoscopy Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 The urinary system is made up of which of the following structures?   Ureters, bladder, kidneys, urethra Ureters, bladder, kidneys, prostate Bladder, kidneys, urethra, urostomy Urinometer, bladder, kidneys, urinary meatus Answer: 1 Rationale: The urinary system is made up of kidneys, ureters, bladder, and urethra in the male and female. The prostate is only present in males and is not considered part of the urinary system. A urostomy is an opening where the ureter exits the abdominal wall to discharge urine. A urinometer is an instrument to measure urine. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Erin’s patient has been complaining of burning when she urinates. Her doctor ordered a urinalysis, which shows pyuria. These results indicate: there is an increased amount of protein. liver disease or an obstruction of the bile duct. there is blood in the urine. there is pus in the urine. Answer: 4 Rationale: Pyuria is pus in the urine, which usually means bacteria are present in the bladder or kidneys. Proteinuria is protein in the urine. Bilirubin in the urine suggests liver disease or an obstruction of the bile duct. Hematuria is blood in the urine. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 29 Lesson 29.2 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory Compare and contrast the purposes and principles of indwelling and intermittent catheterization. Summarize the rationale for using a continuous bladder irrigation system. Analyze different methods of managing urinary incontinence. Clinical Practice Insert an indwelling catheter using sterile technique. (Continued) Perform catheter care. Teach a patient how to perform Kegel exercises. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Urinary Catheters/Specimens Catheter types Robinson Foley Suprapubic Coudé Alcock de Pezzer Malecot Condom Specimen types Routine Midstream Indwelling catheter Sterile 24-hour Strained Inserting a catheter (see Skill 29-2) Ask the students to simply illustrate each different catheter type; discuss the rationale for the different catheter types. (If possible, secure some of the different types listed and pass them around the class.) Ask the students to identify the nurse’s role in caring for the patient with a catheter. Ask the students to identify the essentials of documentation for the patient with a catheter. Ask the students to identify abnormal assessment findings and how they should be documented/reported. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-8: Common urinary catheters Discuss the single lumen urinary catheter and its uses. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-8: Common urinary catheters (cont’d) Discuss the double lumen urinary catheter and its uses. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-8: Common urinary catheters (cont’d) Discuss the triple lumen Alcock urinary catheter and its uses. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-9: Side-lying position for catheterization Discuss when to use side-lying position for catheterization. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 29-10: Suprapubic catheter Discuss the urinary catheter and its uses. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Incontinence Loss of normal bladder control Body image disturbance, Increased risk for impaired skin integrity, Increased risk for infection May be temporary or permanent May be corrected by surgery May be helped by performing Kegel exercises Voiding studies measure the various pressures in the bladder, meatus, urethra, and ureter and include: Uroflowmetry; cystometrogram; urethral pressure profile Cystourethrogram; voiding cystogram Discuss the importance of Kegel exercises. Electromyography—evaluate the neuromuscular function of urination. Discuss the nurse’s role in patient preparation and teaching for diagnostic testing. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Urinary Diversion Necessary when the bladder is removed or bypassed One or both ureters are implanted into: The abdominal wall (urostomy) The bowel A pouch constructed from a piece of bowel Skin care depends on the type of diversion Diversion is usually a result of surgery. May be temporary or permanent. Discuss the rationale for urinary diversion. Ask students to share their experience in caring for a patient with a urinary diversion Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Documentation of Voiding When a patient is voiding normally (voiding sufficiently ) Whether there is a problem voiding (i.e., dysuria) Whether the patient is continent The amount of urine output Any bladder irrigations Presence of an indwelling catheter (or when it is removed) Ask the students to summarize the importance of documentation, when it is okay to document, and when it is important to notify the charge nurse or physician directly. Review the importance of: Ongoing patient assessment of symptoms I&O Patient hydration status Some patients are reluctant to discuss urinary elimination based on age, cultural practice, privacy, and personal preference. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Brenda is making rounds on her postoperative patient. She notices her patient’s Foley has drained 90 mL in 3 hours. Which statement is correct? This is a severe decrease in urine output. This is an average amount of urine output. This is a slightly above-average amount of urine output. This is an excessive amount of urine for a postoperative patient. Answer: 2 Rationale: There should be an average hourly amount of 30 mL urinary output. In 3 hours, 90 mL would be average for an adult. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Erin’s patient will be going home with a catheter. All of the following are true regarding a Foley catheter except: it is the most common type of indwelling catheter. it has two lumens. the balloon is inflated to 15 mL. it may also be used for suprapubic drainage Answer: 3 Rationale: The balloon is inflated 5 to 10 mL. It is the most common indwelling catheter; it has two lumens and may be used as suprapubic drainage. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 Bruce’s patient needs a condom catheter. This type of catheter is used when: the patient cannot void. a man or woman has bladder surgery. a female is incontinent. a male is incontinent. Answer: 4 Rationale: A condom catheter is used only for males who are incontinent but can void on their own. An indwelling catheter is used for a patient who cannot void or for a man or woman following surgery. The female incontinent patient cannot wear a condom. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.