1. THE ASSESSMENT AND CARE FOR IMPAIRED URINARY ELIMINATION PN 134

2. ASSESSMENT Pain on urination Pattern of urination
Strength of urine stream
Urgency, frequency, incontinence, hematuria, nocturia
Intake and output
Urine color, clarity, and odor

3. URINARY RETENTION Urinary retention Etiology/pathophysiology
The inability to void despite an urge to void
Clinical manifestations/assessment
Distended bladder
Discomfort in pelvic region
Voiding frequent, small amounts
URINARY RETENTION
Inability to void when there is an urge to void, acute or chronic
This creates urinary stasis & increases the possibility of infection.
Urine may overflow the bladder’s capacity, causing incontinence.
Possible Causes
Response to stress
Obstruction of the urethra by calculi (concentration of mineral salts – stones)
Tumor
Infection
Interference with the sphincter muscles during surgery
Side effect of medications or perineal trauma
Client may experience discomfort & anxiety
Frequency and voiding small amounts may occur
Distended bladder can be palpated above the symphysis.
Can be chronic or acute; if chronic, bladder can overflow causing urinary incontinence
Clinical manifestations: sometimes vague and overlooked
Distended bladder
Can be palpated above pubic symphysis
Cause discomfort and anxiety
Assessment: subjective: frequency with or with out burning, urgency, nocturia, occassional acute discomfort
Treatments
Analgesics & antispasmodics
Urinary catheter
Surgery – to remove obstacles
Assessments
Check for residual urine after voiding
Residual should be less than 50 mL.

4. URINARY RETENTION Client may experience discomfort and anxiety.
Frequency of urination and voiding small amounts may occur.
Treatment: urinary analgesics and antispasmotics.
Urinary catheter may be used, or surgery if indicated.
When client able to void, check for residual urine-should be less than 50mL.
Residual urine: pt voids amount measured; pt catheterized after voiding and amount measured; amount remaining is residual;
Help pt relax, sitz baths, privacy warm showers, warm beverages. Interventions pg 481.

5. URINARY RETENTION Stasis may lead to infection.
Distended bladder may result.
Caused by stress, calculus obstruction, stones, tumor, infection, medications, trauma.

6. URINARY RETENTION Medical management/nursing interventions
Warm shower or sitz bath
Natural voiding position if possible
Urinary catheter
Surgical removal of obstruction
Analgesics

7. URINARY RETENTION Urinary Analgesics
Pyridium, Pyridate, phenazopyridine:
Uses: relief of pain associated with lower genitourinary tract
Adverse Reactions: headache, rash, pruritis, GI disturbances, discoloration of the urine, sclera and/or skin.
Dosage range: 200 mg TID PO

9. Urinary Incontinence Etiology/pathophysiology
Involuntary loss of urine from the bladder
Total incontinence; dribbling; stress incontinence
Secondary
Infection; loss of sphincter control; sudden change in pressure in the abdomen
Permanent or temporary

10. URINARY INCONTINENCE Stress: leakage of urine on straining.
Urge: sudden need to urinate.
Overflow: full bladder leads to leakage.
Total: no control of voiding.
Nocturnal enuresis: night time incontinence.
URINARY INCONTINENCE
The involuntary loss of urine from the bladder
May be a complication of urinary tract problems or neurologic disorders
May be permanent or temporary
Medications
Sedatives
Hypnotics
Diuretics
Anticholinergics
Antipsychotics
Alpha antagonists
More than 13 million men & women in the U.S. experience incontinence
Women twice as often as men
Affects the client’s emotional, psychological, & social well-being
Can occur with any age but more common in older adults
All types of incontinence can be treated at any age.
Keeping perineal area dry and intact is a goal for all clients
Classifications
Stress
Urge
Overflow
Total
Nocturnal enuresis
STRESS INCONTINENCE
Most common type
Not a disease or a natural, inevitable effect of aging
Anyone can be affect but usually women
Leakage of urine when a person does anything that strains the abdomen, such as:
Coughing
Laughing
Jogging
Dancing
Sneezing
Lifting
Making a quick movement
Walking
Medical Management
Depends on underlying cause
Often can be cured or alleviated
Treatments may include:
Bladder retraining
Medicines, such as conjugated estrogens
Surgery – to restore support of pelvic floor muscles or re-construct sphincter
Collagen injections surrounding urethra
This closes urethra enough to prevent urine from leaking out.
Nonsurgical outpatient setting Support prostheses
External barriers
Kegel exercises (strengthens pelvic floor muscles)
Practice 10 times, 7 or 8 times a day
Planning a schedule of voiding
URGE INCONTINENCE
When a person is unable to suppress the sudden urge or need to urinate
Sometimes urine leaks without warning.
An irritated bladder is often the cause.
Infection or very concentrated urine may irritate the bladder.
Treatments
Clearing up an infection, if present
Encouraging client to have a fluid intake of 3,000 mL/day
Less fluid does not prevent incontinence but may promote infection.
OVERFLOW INCONTINENCE
Bladder becomes so full & distended that urine leaks out
Occurs when a blocked urethra or bladder weakness prevents normal emptying
The blockage may be an enlarged prostate.
The distended bladder cannot contract with enough force to expel a stream of urine.
Occurs most often in persons who: Have diabetes
Drink a large quantity of alcohol
Have decreased nerve function
Bladder retraining may alleviate the situation
TOTAL INCONTINENCE
When no urine can be retained in the bladder
Client may be able to manage with an indwelling catheter.
A neurologic problem is usually the cause.
Surgery to make a temporary or permanent urinary diversion may be required.
NOCTURNAL ENURESIS
Occurs during sleep
Limited fluid intake after 6 pm will help.
However, total fluid intake for each 24 hours should remain the same.
Nursing Management
Identify impaired urinary elimination based on subjective & objective data
Assess vital signs
Encourage adequate fluid intake
Teach Kegel exercises
Initiate bladder retraining

11. Urinary Incontinence Clinical manifestations/assessment
Involuntary loss of urine
Leaking with coughing, sneezing, or lifting
Medical management/nursing interventions
Treat underlying cause
Surgical repair of bladder
Temporary or permanent catheter
Bladder training
Kegal exercises

12. Urinary Tract Infections
Etiology/pathophysiology
UTIs are caused by pathogens that enter the urinary tract – with or without presence of symptoms
Bacteriuria (bacteria in the urine): the most common of all nosocomial infections; often associated with urinary catheters
Common in older people r/t bladder obstruction, insufficient bladder emptying, decreased bactericidal secretions of the prostate, increased perineal soiling in women, sexual intercourse.

13. Urinary Tract Infections
Immobility, sensory impairment, and multiple organ impairment may increase the probability of infection in the older adult
Females more susceptible because shorter urethra and proximity to vaginal and rectal area.

14. Urinary Tract Infections
Gram-negative microorganisms from the GI tract (e.g. E. Coli, Klebsiella, Proteus, or Pseudomonas) commonly cause UTIs. They ascend through the urinary meatus.
Body usually keeps infections in check by washing them from the body through voiding.
If there is incomplete emptying of the bladder or reflux of urine, the retained urine supports growth of bacteria.

15. Urinary Tract Infections
Clinical Manifestations
Urgency, frequency, burning on urination
Microscopic or gross hematuria
Cloudy or blood-tinged urine
Nocturia
Abdominal discomfort, perineal or back pain
Sudden onset incontinence or increased incontinence
Type of infection depends on location: cystitis, urethritis, nephritis, etc.

16. Urinary Tract Infection
Treatment
Pharmacology: antibiotics
Common ones:
Norflaxin (Noroxin)
Nitrofurantoin (Furadantin)
Sulfisoxazole (Gantrisin)
Trimethoprim-Sulfamethoxazole ( Bactrim, Septra)
Pharmacological
Norfloxacin
Nitrofurantoin
Ciprofloxacin
Sulfonamides
Determine allergy to sulfonamides or penicillins
Length of treatment related to type of cystitis, acute or chronic.
Diet
Fluids encouraged – 3 to 4 liters of non-caffeinated fluid per day
Meats & whole grains – urine more acid
Cranberry juice – tannins may prevent e. coli from sticking to cells of urinary tract.
Activity
Clients on bed rest – answer call light promptly
Difficult to empty bladder completely with bedpan.
Orders for bathroom privileges or commode are encouraged.
Nursing Management
Monitor vital signs
Record I&O
Encourage -
Fluid intake, especially water & cranberry juice
Voiding more frequently
Women to void after intercourse
Cotton-crotch undergarments
Advise that Pyridium turns urine red-orange & stains clothing
Change incontinence control product frequently
NURSING PROCESS
Assessment
Subjective Data
Frequency or urgency of urination or nocturia
Becomes annoying & embarrassing, regardless of age or sex.
Burning & pain when voiding
Clients with indwelling catheter – may complain of dysuria, burning, & frequency.
Clients often just do not feel well.
Objective Data
Perineal irritation
Urine will small foul & appear cloudy
Hematuria may be present.
Elderly people may become anorexic & develop a low-grade fever.

17. Urinary Tract Infection
Diagnostic Tests: UA, C&S

18. INFECTIOUS DISORDERS
(pp )
Infectious disorders of the urinary system are called urinary tract infections (UTIs).
2 types – upper & lower
Lower UTIs – affect the bladder (cystitis) & urethra
Upper UTIs – affect the kidneys (pyelonephritis, & acute & chronic glomerulonephritis) & ureters

19. CYSTITIS Inflammation of the urinary bladder.
Caused by escherichia coli, candida albicans, coitus, prostatitis, diabetes mellitus.
Culture, sensitivity testing, antimicrobial medication, urinary tract analgesic.
Increase fluid intake, record I & O.
CYSTITIS
Inflammation of the urinary bladder
More common in females – short urethra allows bacteria to ascend through the urethra from the vagina or rectum to the bladder.
Also, bacteria from an infected kidney can descend through the ureter into the bladder
Most UTIs are caused by Escherichia coli.
Other common causes:
Coitus
Prostatitis
Diabetes mellitus
As women age, pelvic floor muscles relax, leading to decreased ability to empty the bladder completely.
In men, usually secondary to another infection.
Bacteria in bladder multiply, causing redness & swelling of bladder wall.
Results in frequency, dysuria, pyuria, hematuria, sometimes burning & urgency
Symptoms increase as bladder distends.
Clean-catch midstream urinalysis showing >100,000 organisms/mL confirms diagnosis. Microscopic exam will also show hematuria & pus.
Med-Surg Management
Medical
Medications & fluids
Ineffective treatment can result in recurrence.
C&S obtained before administration of antimicrobial

21. CYSTITIS
Encourage fluid intake. Should drink between 3-4 liters of non-caffeinated fluid a day.
Intake of meats and whole grains makes the urine more acidic and may discourage growth of bacteria in the urinary bladder.
Drinking cranberry juice
Client Teaching See Nursing diagnosis for a client with cystitis (Impaired Urinary Elimination & Deficient Knowledge) pp
Encourage large amount of fluid intake
Pyridium – explain that it will stain
Importance of taking all medication ordered
Clean perineum from front to back
Cotton crotch
Tight jeans & long bike rides – may irritate the perineum
Avoid perfumed perineal products
Spermicidal contraceptives can be irritating
Void more frequently
Women void after sexual intercourse
Teach elderly persons to change incontinence control products frequently

22. PYELONEPHRITIS
Bacterial infection of renal pelvis, tubules, interstitial tissue of one or both kidneys. Also known as pyelitis or nephropyelitis.
Usually associated with pregnancy, chronic health problems such as DM, polycystic or hypertensive kidney disease, insult to the urinary tract such as catheterization, infection, obstruction, or trauma
PYELONEPHRITIS
Bacterial infection of the:
Renal pelvis
Tubules
Interstitial tissue - of one or both kidneys
Also known as pyelitis or nephropyelitis
Bacteria generally ascend from the urinary bladder through the ureter & enter the kidney in the area known as the renal pelvis.
Bacteria can also enter from the blood & lymph.
Can be secondary to:
Ureterovesicular reflux
When urine cannot drain from the pelvis of the kidney – obstruction
May also occur:
During pregnancy
With prostatitis
When bacteria are introduced during a cystoscopy or catheterizationTrauma of the UT
Can be acute illness or chronic condition
Leads to development of high blood pressure and/or chronic renal failure
Escherichia coli – most often cultured
Inflamed kidney becomes edematous – renal vessels congested
Urine usually cloudy, containing mucus, blood, & pus.

23. PYELONEPHRITIS
Kidney becomes edematous, inflamed; blood vessels congested
Urine may be cloudy and contain pus, mucous, and blood
Small abscesses may form in the kidney
Symptoms of acute condition: chills, fever, flank pain, prostration

24. PYELONEPHRITIS
Repeated episodes  chronic pyelonephritis and atrophy of the kidney with nephrons being destroyed.
Destruction of nephrons  Azotemia: retention in the blood stream of excessive amounts of nitrogenous compounds
Treat to prevent from becoming chronic

25. PYELONEPHRITIS
Diagnostic tests could be: IVP, UA and C&S, CBC, BUN, serum creatinine.
Collect urine specimens before administering antimicrobials
Pharmacology: sulfonamides (Bactrim,Cipro); antipyretics if with fever, analgesics if in pain.
Med-Surg Management
Medical
Diagnostic tests:
IVP
Urinalysis with C&S
CBC
BUN
Serum creatinine
Pharmacological
Sulfonamides
Antimicrobial ciprofloxacin hydrochloride
Antipyretics
Analgesics
Diet
Light diet during febrile stage
Fluids increased to 3,000 m/L/day
Activity
Disease process will cause fatigue.
Bed rest during acute phase
Diversionary activities

26. Immunological Disorders of the Kidney
Nephrotic syndrome
Etiology/pathophysiology
Physiologic changes of the glomeruli interfere with selective permeability
Clinical manifestations/assessment
Proteinuria; hypoalbuminemia
Generalized edema
Anorexia
Fatigue
Oliguria

27. Nephrotic Sydrome

28. Immunological Disorders of the Kidney
Medical management/nursing interventions
Corticosteroids
Diuretics
Diet
Low sodium
High protein

29. Immunological Disorders of the Kidney
Nephritis (acute glomerulonephritis)
Etiology/pathophysiology: in taking a health hx., will usually find that an infectious disease process triggers an immune response.
Frequently a beta-hemolytic streptococcus (2-3 weeks prior)
The immune response  inflamed glomeruli excretion of RBCs and protein in the urine

30. Immunological Disorders of the Kidney
Clinical manifestations/assessment
Edema of the face – esp. around eyes
Pallor
Malaise
Anorexia
Dyspnea with exertion
Hematuria – “cola” colored  frank bleeding
Changes in voiding patterns
Oliguria; dysuria

31. Immunological Disorders of the Kidney
Diagnostic Tests: Blood tests will usually show: elevated BUN, serum Creatinine, potassium, ESR, and antistreptolysin-O titer.
Urinalysis will show presence of RBCs, casts, and protein
Treatment includes drug therapy, diet, and rest.
Treat to prevent renal complications, cardiac complications, and complications to cerebral functioning.

32. Immunological Disorders of the Kidney
Medical management/nursing interventions
Antibiotics
Treat primary symptoms
Diuretics
Antihypertensives
Diet
Protein and sodium restrictions
Increase calories

33. Immunological Disorders of the Kidney
Pharmacology
Prophylactic antimicrobial therapy possible
Drug of choice is Penicillin
Diuretic and antihypertensive drugs may be ordered
Corticosteroids, chemotherapeutic drugs, and/or immunosuppressive drugs to control inflammatory response.
Pharmacological
Prophylactic antimicrobial therapy - penicillin
Diuretic & antihypertensive medication
Drugs to control inflammatory response
Diet
Fluid restriction due to fluid retention
Adjusted according to I&O & weight
Protein regulated to rest kidneys
Potassium replaced
Sodium restricted to prevent fluid retention
Activity
Physical & emotional rest are essential.
Bedrest until inflammation has subsided, urinary flow increases, & as long as hematuria or proteinuria.
Strict turning schedule – skin breakdown with edema

34. Immunological Disorders of the Kidney
Nursing Interventions
Focus is on control of symptoms and prevention of complications
Monitor level of consciousness if BUN is elevated
VS , I/O
Bedrest and fluid adjustments are guided by urine output until diuresis is adequate
Level of Activity: depends on the degree of edema, BP, proteinuria, and hematuria – all of which increase with excessive activity
ACUTE GLOMERULONEPHRITIS
A condition that can affect one or both kidneys
In both acute & chronic disease, the glomerulus within the nephron unit becomes inflamed.
Predominantly a disease of children & young adults – when the cause is bacterial.
Viral form can affect all ages.
Prognosis
For most clients – full recovery
Some may develop chronic glomerulonephritis
Approximately 1% to 2% of people with end-stage renal disease from acute glomerulonephritis
Acute glomerulonephritis during childhood is known as Bright’s disease.
Mechanism
Most clients develop symptoms 1 to 3 weeks after:
An upper respiratory infection (tonsillitis or pharyngitis with fever)
Skin infection caused most commonly by group A -hemolytic streptococcus
Infection triggers an autoimmune response & glomeruli are attacked by antibodies at the site of the glomerular basement membrane, resulting in inflammation.
Some clients are asymptomatic.
A nephrotoxic drug or systemic disease such as diabetes or lupus may also be a cause.
Med-Surg Management
Medical
Drug therapy
Diet
Rest
Focus on prevention of renal, cardiac & cerebral complications
Diet: salt not restricted usually
If BUN elevated: protein restricted, liberal carbs, may have sodium restriction if low urine output indicates impaired renal function
Potassium according to individual needs…if oliguria becomes severe, renal clearance of potassium is impaired
Water: according to urine output, may not need restriction

35. Immunological Disorders of the Kidney
Patient Teaching
Nature of illness
Effect of diet and fluids on fluid balance and sodium retention
Diet: prescribed sodium and fluid restriction
Info on protein restriction/ CHO sources for energy
Medication
Pacing daily activities
Avoiding trauma and infections
S/Sx that require medical attention
Importance of medical follow up

37. Immunological Disorders of the Kidney
Nephritis /Chronic Glomerulonephritis)
Etiology/pathophysiology
Slow, progressive destruction of glomeruli
Commonly caused by other chronic illnesses
Diabetes mellitus
Systemic lupus erythematosus

38. Immunological Disorders of the Kidney
Clinical manifestations/assessment
Malaise; morning headaches
Dyspnea with exertion
Visual and digestive disturbances
Generalized edema
Weight loss
Fatigue
Hypertension
Anemia
Proteinuria

39. Immunological Disorders of the Kidney
Chronic Glomerulonephritis (cont.)
Medical management/nursing interventions
Same as acute glomerulonephritis
Bedrest, dietary modification, medication
Goal: prevent further renal damage; prevent cerebral and cardiac complications
Renal dialysis
Kidney transplant

40. Immunological Disorders of the Kidneys
Pharmacology
Antimicrobial therapy given prophylactically
Diuretics and antihypertensive drugs ordered
Pharmacological
Diuretic & hypertensive medications are ordered.
Antimicrobial therapy – prophylactically
Diet
Fluid intake is adjusted to urinary output.
Protein in diet regulated
Sodium & potassium restriction determined by serum electrolyte levels
Carbohydrates increased to provide energy
Activity
Bed rest if hematuria or albuminuria
Nursing Management
Assist client -With ADLs, encourage bed rest with diversional activities
To reposition frequently & assess skin
Measure urine hourly or as ordered
Assess –
Color, consistency of urine
Lung sounds, edema, speech & mental functioning
Weigh client daily
Monitor laboratory reports
NURSING PROCESS
Assessment
Subjective Data
Client may complain of:
Morning headache
Pruritis
Decreased ability to concentrate
Fatigue
Dyspnea
Facial edema
Objective Data
Fluid retention becomes evident, leading to shortness of breath, especially at night.
Vital signs, usually hypertension
Lung sounds every shift – crackles – sign of fluid retention
Weight daily, degree of edema, pitting or nonpitting
Urine becomes pale & dilute
Client Teaching See Nursing diagnosis for a client with chronic glomerulonephritis (Anxiety), p. 1013
Assist client to express concerns about possible dialysis

41. PHARMACOLOGY Thiazides: hydrochlorothiazide Loop diuretics
Types of diuretics:
Thiazides: hydrochlorothiazide
Loop diuretics
Potassium sparing diuretics
Osmotic diuretics
Carbonic Anhydrase inhibitor diuretics
Monitor output, maintain fluid restrictions and weigh daily. Monitor for fluid overload; changes in pulse rates, respirations, cardiac sounds, lung sounds.
Accurate I&O V?S q 4 hrs until stabilized; no over use of salt ; addition of potassium (baked potatoes, apricots, raw bananas, navel oranges); sometimes potassium sibs needed.
May be potentiating effect with other meds as diuretic begins to work.
Loop diuretics: useful if greater diuretic effect is desired. Furosemide (Lasix)

42. PHARMACOLOGY Diuretics: -drug that increases the secretion of urine.
-kidney disease often causes excess fluid retention
(edema).
-many different types of diuretics used for different
purposes.

43. PHARMACOLOGY Antihypertensives methydopa (Aldomet)
minoxidil ( Loniten)
hydralazine HCL ( Apresoline)
Monitor BP, pulse, postural hypotension, and K, Na,Cl, and CO2 and I&O

44. PHARMACOLOGY
Phosphate binding antacids: aluminum hydroxide gel ( Amphogel)
Potassium exchange: sodium polystrene
Electrolyte Replacement: calcitrol (Rocaltrol)