Basic function

alterations can cause physcal and emotional changes

need to find cause of problem in order to help find an acceptable solution

transport urine from kidnys to bladder

peristolic waves cause urine to enter bladder

compressed during micturition to prevent backup of urine from bladder to kidneys

obstruction (like renal calculi) causes strong peristolasis in attempt to remove blockage-very painful

reservoir for urine until the urge to urinate develops

they regulate composition of blood

prevent buildup of wastes and extra fluids

keep elctrolyte levels stable (sodium, phosphate, and potassium)

make hormones that regulate blood pressure, make red blood cells, and keep bones strong

possible circulatory, blood volume, or renal alterations

need to find out why

a hormone that functions within bone marrow to stimulate RBC production and prolongs RBC life

produced by kidneys

pts with chronic renal disease cannot produce enough and therefore are prone to anemia

produced by kidneys

affects blood pressure

produce substance that converts vitamin d into its active form

pts with chronic renal disease do not make sufficient amounts therefore are prone to deminerlization of bones caused by impaired calcium absorption

through layer of skeletal muscle called pelvic floor muscles

contraction of these muscles make it possible to prevent flow of urine through urethra

female-2in

male-8in

many facors influence volume and quantity or urine and and pt's ability to urinate

can be acute and reversible or chronic and irreversibe

disease condtions

medications and medica procedures

sociocultural factors

psychological factors

fluid balance

positioning

pre-renal

renal

post renal

narrowing of urethra

weakened pelvic/perineal muscles (after pregnancy)

diabetes mellitus (type 1) due to nerve and musculoskeltal changes

enlarged prostate-blocks flow

alzheimers due to loss of ability to sense a full bladder (cognitive impariment)

any dsease or illness that makes it difficult to get to the bathroom

end stage renal disease-uremic syndrome

increase in nitrogenous wastes in blood

fluid & electrolyte imbalances

nausea

vomiting

headache

coma

convulsions

agressive treatment is required for survival

MUST BALANCE ELCTROLYTE LEVELS

requires machine with semipermeable filtering membrane (artificial kidney) to filter and remove waste products and extra fluid from blood.

requires vascular access or renal shunt

requires catheter into abdomen's peritoneal cavity.

a sterile electrolyte solution is instilled into the peritoneal cavity. it remains in cavity for prescribed tme an is then drained out. this is done by gravity and not machines, waste is pulled out with draining fluid.

when renal failure can no longer be controlled by deitary modifications and administration of medcations to correct electrolyte abnormalities

worsening of uremic syndrome associated with ESRD (nause, vomiting, neuro changes- any altered mental state is a neuro change)

severe eletrolyte and/or fluid abnormalities

replacement for failed kidne with helthy one from a live person or cadaver donor

immunosuppresant medications are administered for to help prevent rejection of organ

lungs, skin, respiritory tract

immeasurable

excessive perspiration losses is a lot of insesnsible water loss- decreases urine production

causes increase in mtabolic demands of body and accumulation of body wastes-urine volume decreased and concentrated

NPO-less urine output

underlying disease that affect fluid balace prior to surgery

anesthetics and narcotic analgesics slow glomerular filtration rate thus reducing urine output. also impair sensory and motor impulses decreasing ability to sense bladder fullness and inhibits mitruition

spinal anesthetics create risk or urinary retention due to inability to sense need to void and inability of bladder muscles and urethral shpincters to respond

surgery of lower abdomen and pelvic structures can impair urination due to local trauma surrounding tissues

patients usually have urinary catheters in place after surgeries involving ureters, bladder, and urethra

antipsychotics

antidepressants

alpha-adrenergic agonists

calcium channel blockers

overflow incontinence

alpha-antagonists

diuretics

sedative hypnotics

opiod analgesics

ACE inhibitors

antihisthamines

meds!

especially with older patients

incontinence

frequency

urgency

urinary retention

UTI

a diagnostic tool for the urinary system

requires pt's to limit fluids before the test causing decreased output.

must check for iodine/dye allergies prior to IVP and push fluids post test to flush out dye

diagnosic tool for urinary system

involves direct visualization of urinary structires (eg cytoscopy)

may cause loaclized edema and spasm of bladder sphycter

pt's may have difficulty voiding or red/pink urine post-exam

overflow develops

pressure buids to the point where the sphyncter temporarily opens and a small amount of urine is released

this relese is enough for the sphinctr to close again

this can occur 2-3 times per hour with no relief, or may continually dribble urine

volume of urine remaining in the bladder after normal voiding 

use a blader scanner to measure the residual urine

straight catheterize the pt to remove the residual urine

sometimes just a matter of privacy and comfort-try sitting pt up

most common health-care aquired infection

80% reuslt from use of indwelling catheter

increased hospitalizations

increased morbidity and mortality

longer hospital stays

increased hospital costs

soap and water

sanitizer does not kill spores

bacteria in urine

can lead to bacteria in kidneys and sometimes even bloodstream (bacteremia)

poor perineal hygeine

inadequate hand washing

females wiping back to front

female sexual intercourse

need to teach pt's how to wipe

infection in the upper urinary tract or kidneys

S/S- flank pain, tenderness, fever, chills

unrine is diverted to an external source

can be permanent or temporary

bypasses urethra and bladder

stoma (artificial opening)

drain urine

this pt will have special needs

urinary reservoir made form distil portion of ileum

neobladder

reservoir made from distil portion of ileum, ueturs embedded into it

narrow segment of ileum brought out through abdominal wall to form stoma

ileocecal valve prevents urine flowing outside the abdomen

pt's will have to self catheterize 4-6 times per day for the rest of their lives

incontinent urinary diversions

surgeries involve connecting the ureters to a section of ileum with a formation of a stoma on the abdominal wall

unrine drains constantly and pt has no control over the flow-drainage bag required

the ostomy nurse

will meet prior to proedure and again after to help the pts/families with technique and sizing of drainage bags

the urinary tract is sterile

use sterile technique when catheterizing a patient

use mdical asepsis for perineal care

age

environment

medications

psychologicalissues

muscle tone

fluid balance

surgical or diagnostic procedures

pregnancy

aging

being overweight

caffeine (relaxes smooth mscle of sphycter)

disease conditions

trauma

raised toilet seats

grab bars

portable commodes

facilitate more frequent opportunities to void

encourage older adults to emppty bladder before meals, after meals, and at bedtime

encourage 6-8 glasses of water per day as diluted urine discourages bacterial growth

discourage caffeine products and alcohol as they have a diuretic effect and increase urintion

drink cran juice and take vitamin c to incerase acidity of urine and help decrease UTIs

note the incontinence is NOT a normal part of aging

avoid routine use of indwelling catheters because the greatly increase risk of infection

assess

diagnosis

plan (measurable and specific)

implement

evaluate (let pt tell you if it is working)

gather nursing history for pt's urination pattern and smptoms, the factors affecting urination

conduct physical assessmen of pt's body systems potentially affected by urinary change

assess characteristics of urine (color, clarity, odor)

assess the pt's perception of urinary problems as it affects self-concept and sexuality

gather relevant laboritory and diagnostic and test data

infection

reflux of urine

nature of problem

signs and symptoms

onset and duration

severity

predisposing factors

effects on pt

nurse knowledge for assessment

physiology of fluid balance

anatomy and physiology of normal urine production and urination

pathophysiology of selected urinary alterations

factors affecting urination

principles of communication used to address issues related to self-concept and sexuality

caring for pts with alterations in urinary elimination

caring for pts at risk for urinary infection

personal experience with changes in urinary elmination

maintain ots dignity and privacy

apply intellectual standards to ensure ot histaory and assessments are complete and in depth

apply professional standards of care from professional organizations like ANA, International Continence Society (ICS), and United Ostomy Associations of America

display humilty in recognizing lmitations in knowledge

establish trust with he pt to reveal full picture of this potentially sensitive area of assessment

urine sampling from indwelling cathter

random (routine urinalysis)

clean-voided or midstream (culture and sensitivity)

sterile specmen (culture and sensitivity)

timed urine specimens (for measuring levels of adrenocortical steroids or hormones, creatine clearance, or protein quality tests)

collect during normal voiding or from indwelling catheter or urinary diversion bag. do not collect from indwelling cath drainage bag

use clean specimen cup

clean-voided or midstream

(culture and sensitivity)

sterility

use double void

sterile specimen cup

if indwelling cath, use port and remember to clamp below port to allow urine to collect

measures levels of adrenocortical seroids or hormones, creatine clearance, or protein quality tests

may be 2, 12, or 24 hour collections

begins after pt urinates and ends with final voiding at end of time period

pt voids into clean recepticle, then urine is transferred into special collection container which may have special preservatives.

each specimen must be free of feces and toilet tissue

missed specimens make entire collection inaccurate

check agency policy

pH

protein

glucose

ketones

blood

specific gravity

microscopic examination contains:

RBCs

WBCs

Bacteria

Casts

Crystals

4.6-8.0

indicates acid base balance

cid pH helps protect against bacterial growth

urine that stands for several hours becomes alkiline

0-8mg/100mL

normally not present in urine

common in renal disease because damage to glomeruli or tubules allows it to enter

none

patients with diabetes mellitus often have glucose in urine as a result of inability of tubules to resorb high glucose concentratins (>180mg/100mL)

ingestion of high concentrations of glucose causes some glucose to appear in the urine of healthy persons

none

patients whose diabetes mellitus is poorly controlled experience breakdown of fatty acids. 

end products of fat metabolism are ketones

some people with dehydrtion, starvation, or excessive aspirin usage also have ketonuria

a positive test for occult blood occurs when intact eryhrocytes, hemoglobin, or myoglobin is present.

blood in a routine specimen in a woman may be a result of contamination by menstrual fluid

1.0053-1.030

measures concentration of particles in urine

high reflects concentrated urnie, and low reflects diluted.

dehydration, reduced renal blood flow, and increased ADH secretion elevate SG. overhydration, early renal disease, and inadequate ADH secretions reduce SG.

up to 2

damage to glomeruli or tubules allows RBCs to enter urine.

trauma, disease, or surgery of lower urinary tract also causes blood to be present.

0-4 per low-power field

greater number indicates UTI

none

bacteria indicate UTI 

pt does not aways have symptoms

none

casts are cylindrical bodies the shapes of which take on likeness of objects within the renal tubule.

types include hyaline, WBCs, RBCs, granular cels, and epithelial cells

increased presence is always an abnormal finding and indicates renal altercations

none

crystals are the result of food metabolism

excess crystals such as uric acid or calcium phosphate result in renal stone formation

noninvasive:

abdominal roentgenogram

computerized axial topography

intravenous pyelogram

renal or bladder ultrasound

urodynamic testing

invasive:

endoscopy-cytoscopy

arteriogram (angiography)

(plain film; kidney, uretur, bladder [KUB], or flat plate

determine size, shape, symmetry, and location of the kidneys

no special precautions needed

obtain detailed images of structures within a selected plne of the body

the computer reconstructs cross-sectional images and thus allows the  healthcare provider to view pathological conditions such as tumors and obstructions

bowel cleaning per agnecy or health care provider preference

assess for shelfish (iodine) allergy if CT with contrast is ordered

view the collecting ducts and renal pelvis and outline the ureters, bladder, and urethra

a special intravenous injection (iodine-based) that converts to a dye in urine is intravenously injected.

bowel cleaning per agency

only clear liquids until after test is completed

assess for allergies before test

after test encourage fluid intake to flush dye from system

observe for late symtoms of allergy (rash)

identify gross renal structures and strutural abnormalities in he kidney using high-frequency, inaudible sound waves

no bowel cleansing needed

identify structural abnormalities of bladder or lower urinary tract.

also used to estimate volume of urine in bladder

if needed, ask pt to drink fluids before test to cause bladder distension for better results

determines bladder muscle function and evaluates causes of urinary incontinence

generally pt urinates into a toilet equipped with a funnel and uroflowmeter

voiding activates uroflowmeter and electronic data are recorded and analyzed

nurse must explain procedure to patient then provide materials for perineal hygeine

provides direct visualization, specimen collection, and/or treatment of the interior of the bladder and urethra.

usually performed using local anesthesia, general anesthesia or concious sedation is more common to avoid unneccessary anxiety and trauma for pt.

surgery on male prostate is also perfored using a special endoscope.

obsain signed consent and complete bowel cleaning if instructed.

follow agency policy for preoperative preparation and checklist.

after pt returns, assess vital signs and characteristics of urine, monitor intake and output, encourage fluids, and observe for fever, dysuria, and pain in suprapubic region.

visualize the renal arteries and/or their branches to detect narrowing or occlusion.

catheter is placed in one of femoral arteries and introduced up to level of renal arteries. radiopaque contrast is injected through the catheter whiel x-ray film images are taken in rapid succession.

obtain signed consent

assess for allergies

follow agency checklist

after procedure monitor vital signs frequently until stable.

pt maintains bed rest for prescribed time.

encourage fluid to flush contrast from system.

monitor affected extremity for neurocirculatory function (pulse, skin temp, sensation, and mvement) and observe catheter site for bleeding, swelling, increased tenderness, or hematoma formation.

notify healthcare provider immediately if and procedural abnormality

these 2:

note any aallergies

encourgae fluids after the procedure

social isolation

disturbed body image

urinary incontinence (functional, stress, urge, overflow)

pain (acute, chronic)

risk for infection

toileting self-care deficit

impaired skin integrity

impaired urinary elimination

constipation

urinary retension

involve pt/family when making goals

make a short and long term goal

make sure goals are measurable and acheivable

set goals according to priorities (esp with mult diagnoses)

reinforce adherence to good hygeine practices

select interventions that promote normal physiology of muctruition

involve family in lerning knowledge and skills for pt's care in the home

refer pt to appropriate health care proffesionals/agencies

importance of caring in maintenance of pt's self-esteem

role other helth professionals might provide in the care of pt's with urinary elimination alterations

adult learning principles to apply when educating the pt and family

services of community-based resources

nursing interventions effective in maintainign normal urinary elimination

individualize interventions to adapt to a normal urination pattern

apply standards of care from the agency and professional organizations such as ANA, ICS, and United Ostomy Associations of America when planning care

incorporate individualized health promotion activities and therapeudic intervetions to meet the patients needs

collaborate with other health professionals

(physical therapist tech to teach Kegels)

consider home environemtn

maintain normal habits as best as possible while hospitalized (privacy, fluids, pts normal routine)

indwelling (foley)

straight

at urethral meatus

at port

at drain

helps finse fluids

usually after prostate surgery because of clots clogging catheter

loss of urine caused by factors outside the urinary tract (ex. had to void but could not get to bathroom in time)

clothing modifications

scheduled toileting

absorbent products

environment changes

involuntary leakage of urine due to increased abdominal pressure (exercising, coughing, sneezing)

kegel exercises, surgery, absorbent products, electrical stimulation

involuntary pssage of urine after strong sense of urgency to void (often happens more than every 2 hours with bladder spasms/contractions)

medications

biofeedback

behavioral modifications

kegel's

absorpbent products

lifestyle changes (wt loss, fluid modifications)

promote normal micturtion by having pt sit instead of laying on bedpan

have males stand at bedside if possible

sound of running water helps

pour warm water over perineal area

follow pt's home routine if possible

maintain optimal fluid intake

medications

catheterization

tips for preventing infection in pts with catheters

hand hygeine

do not allow any part of cath to sit on floor (eg bag)

use sterile technique to collec specimens

keep seperate receptacles for emptying urine

prevent pooling of urine in tubing

prevent reflux of urine back into bladder

keep bag below bladder level

secure tubing to pt's leg

perform perineal care 3x daily AND prn

encourage fluids if allowed

remove cath as soon as poss

combination of urge and stress incontinence

intervention based on symptoms most bothersom to pt

involuntary loss of urine at intervals without the sensation of urge to void. clent unaware of bladder filling and reflex empyting occurs when bladder is full

intermittant catheterization

condom caths

crede's method

hyperactive/overactive bladder incontinence interventions

urinary urgency that is associated with urinary frequency and nocturia

kegel's

bladdr training

biofeedback

limited carbonated bevs

fluid intake 1.5-2L's per day

be sensitive to changes in self-concept/image

ask:

how frequently are you voiding?

do yo continue to have the feeling of urgency?

have the symptoms decreased since you've decreaced your caffeine intake?

do you still have burning when you void?

do you still have pressure in your lower abdomen?

clinical signs of normal micurition

characteristics of normal urine

behaviors that demonstrate learning

use expected outcomes established in pt's plan of care

use established expected outcomes from professional organizations such as ANA and AHCPR to evaluate pt's response to care

relaxes smooth muscles in urinary tract

class: urinary antispasmotic, anticholinergic

decreased dysuria, frquency, nocturia, and incontinence

used to treat overactive bladder (urinary frequency, urgency, and incontinence)

TALL letter safety spelling

Nursing considerations: asess urinary patterns & for bladder distention

monitor EKGs (can prolong QT intervals)

assess for allergic reactions

interacts ith st johns wart and grapefruit juice

may cause constipation or blurred vision

Acts on ascending loop of Henley in Kidneys, inhibiting reabsorption of sodium and chloride. causing excretion of sodium, magnesium, chloride, water, and some potassium

class: loop diuretic

decreses edema in lungs and peripherally which causes a decrease in blood pressure

used to treat pulmonary edema, CHF, ascites, HTN, and more

Nursing considerations:

can cause ototoxicity (ear)

hypokalemia (flushes K out)

nocturia

polyuria

hypotension (fast increase of output)

administer in morning to help with nocturia

record accurate I&O's

pt education and safety due to frequent voiding