Urinary Elimination

Physiology of urinary system: Kidney & Ureters; the kidney are located on either side of the vertebral column behind the peritoneum, in the posterior portion of he abdominal cavity, one of the more significant functions of the kidneys is to help maintain the composition and volume of body fluids. The kidneys filter and excrete blood constituents that are needed and retain those that are; urine is the waste products excreted by the kidneys contain organic, inorganic and liquid wastes.

Nephron is the basic structural & functional unit of the kidneys, there are about 1 million nephrons in each kidney. Nephron removes the end products of metabolism such as urea, creatinine, and uric acid from the blood plasma and form urine, urine from the nephrons empties into the pelvis of each kidney From kidney urine is transported by rhythmic peristalsis through the ureters to the urinary bladder

Urinary bladder; the ureters enter the bladder obliquely and a fold of membrane in the bladder The urinary bladder is a smooth muscle sacs that serves as a reservoir for urine; there are 3 layers of muscle tissues in the bladder that are called Dextrusor muscle Urethra conveys urine from the bladder to the exterior of the body. The desire to empty bladder occurs when the pressure increase lead to stimulate nerve that called Stretch receptors

Urethra; the urethra's function is to convey urine from the bladder to the exterior. The males differ than females. Males about 13.7-16.2cm consists of prostates, the membrane and the cavernous portions, the external sphincter is under voluntary control. The females about 3.7-6.2cm and the muscle at the meatus is called External sphincter.

Act of Maturation; is the process of emptying the bladder, the nerve centers for maturation are situated in the brain and the spinal cord. Voiding is largely an involuntary reflex act, but its control can be learned Frequency of maturation; the frequency depended on the amount of urine being produced

Factors affecting maturation Developmental considerations; an infant's urine is usually very light in color and without odor, most children develop urinary control between the age 2-5 years when daytime control precedes nighttime control, and girls generally develop control earlier than boys Toilet Training; most children begins to control urination voluntarily at 18-24 months of age, toilet training should not begin until the child is able to: Hold urine for 1-2 hours Recognize the feeling of bladder fullness Communicate the need to void and control urination seated on the toilet

Enuresis; is involuntary urination that occurs after an age when continence should be present Involuntary passing of urine when control Should be established (about 5 years of ages ) . Nocturnal enuresis or bed wetting . Involuntary passing of urine during sleep . Bed – wetting should not be considered a problem until after the age of 6 .

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 Nocturia; because the kidneys is unable to concentrate urine, frequency of urination during the night Decrease muscle tone decrease the capacity of bladder to hold urine Decrease bladder contractibility may lead to urine retention; urine retention occurs when urine is produced normally but not appropriately excreted from the bladder due to many reasons e.g. prostate. Weakness in muscle may lead to urine incontinence which is any involuntary loss of urine

Food and fluids; when the body is functioning well the kidneys help to maintain a careful balance of fluid intake and output, caffeine such as coffee; cola, tea have a diuretic effect and increase urine production. Psychological variables; here we have to take care about privacy, stress that interfere with relaxation of perineal muscles. Stress= more frequent + smaller amount of urine

Activity & muscle tone, exercise increase muscle tone, catheterization decrease muscle tone, activity increase metabolism causes decrease muscle tone include child bearing, menopausal or trauma Pathological conditions; certain renal and urologic problems can effect both the quantity and quality of urine produced e.g. UTI, HT, DM

Medications; certain drugs effect urine production, such as Diuretics which commonly are used in the treatment of hypertension prevent reabsorption of water and certain electrolytes in the tubules. And there are certain drugs can cause urine change color include the following : Anticoagulants may cause hematuria which is blood in urine Diuretics can lighten urine color to pale yellow

Injury to the bladder and urethra . Dysuria :Voiding that is either painful or difficult . Causes : UTI . Injury to the bladder and urethra . Urinary hesitancy : Delay and difficulty in initiating voiding is associated with dysuria .

Nursing management Assessing : Nursing history . Physical assessment ( genitourinary system , hydration status , examination of the urine ). 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 . Measuring urinary output - Normally the kidneys produce urine at a rate of approximately 60 ml per hour or about 1500ml/day .

Blood tests [ urea , creatinine ] used to evaluate renal function Measuring residual urine Residual urine ( urine remaining in the bladder following the voiding ). 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 24 hour urine and serum creatinine levels to determine the glomerular filtration rate , a sensitive indicator of renal function Measuring residual urine

Assessment Measures Measuring urine output, measuring the patient's intake and output is an important nursing responsibility. Measuring may be through collecting the urine the pt has indwelling catheter, or through collecting urine and doing urine analysis or through catch-midstream specimen or urine culture 2. Assisting with diagnostic procedures such as cystoscopy, IVP, ultra sound, or KUB

Promoting Normal Urination Maintaining normal voiding habits through: Schedule b) Privacy c) Position d) Hygiene Promoting fluid intake; 2-2.4L/daily Strengthening muscle tone through doing Kegal exercise; strengthen pelvic floor muscles in women and can reduce episodes of incontinence.

By stopping urination mid stream or by tightening the anal sphincter Stimulating urination & resolving urinary retention. Urine retention occurs, the bladder continues to fill and may distend to hold 3000-4000 ml of urine, retention is often temporary such as occurs commonly after surgery involving the lower abdomen, pelvis, bladder or urethra Assisting with toileting in toilet, commode & urinal

a) Postmenopausal women b) Catheterization c) DM d) Old age Preventing UTI: UTI in woman is more susceptible to infection due to shorten of the urethra more than male; the risk factors for UTI: a) Postmenopausal women b) Catheterization c) DM d) Old age

Treatment of UTI: Drink 8-10 glasses of water daily Observe the urine for color, amount, odor, frequency Dry the perineal area after urination or defecation from front-back "urethra-rectum" Take showers rather than baths Wear cotton underwear, avoid tight & restrictive on the lower half of the body Void at frequent intervals

Catheter; is the tube for injecting or removing fluids 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 s infection acquired in hospital

Types of catheters Indwelling 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

Assisting with urinary diversion Obstructions or tumors in the urinary tract may require some pts to have urinary flow diverted surgically, an Ileal Conduit is a surgical diversion of the ureters to the ileum rather than the bladder, in this case the urine is excreted through the stoma is surgically created opening on the body surface.

The nurse as a role model Empty the bladder completely at regular intervals Respond to the urge to void e.g. don't routinely postpone voiding because of being too busy Drink 8-10 glasses of water daily Respond to changes in urinary characteristics "frequency" by seeking their cause & getting medical assistance Monitor use of caffeine that promote voiding & may interfere with sleep Avoid foods that contain excess sodium