URINARY ELIMINATION

Four Major Parts of Urinary System

1. Upper Urinary Tract: 2 Kidneys and 2 Ureters 2. Lower Urinary Tract: Urinary Bladder, Urethra Kidneys Paired, reddish brown, bean shaped organ located on either side of the spinal (vertebral) column, behind peritoneal cavity Right kidney is slightly lower than left due to the position of the liver Primary regulators of fluid and acid base balance in the body Each kidney has its own blood supply o Renal artery originates in abdomen & enters kidney at hilum o Renal vein exits kidney thru hilum and joins inferior vena cava Nephrons functional units of kidneys. Each kidney has 1 million nephrons that filters blood & removes metabolic wastes. Parts of Each Nephron (Chronological Order)
1. Glomerulus

2. 3. 4. 5.

Tuft of capillaries surrounded by Bowmans Capsule. Its endothelium is permeable allowing fluid and solutes to move across here into the capsule. Plasma proteins and blood cells are too large to pass this membrane. Glomerular filtrate is made up of water, electrolytes, glucose, amino acids and metabolic wastes

Bowmans Capsule Proximal Convoluted Tubule (PCT) wherein most water and electrolytes are reabsorbed Loop of Henle glucose are reabsorbed, but other substances are secreted into filtrate, concentrating the

urine.
Distal Convoluted Tubule (DCT)

6.

Additional water & sodium are reabsorbed by AntiDiuretic Hormone (ADH) and Aldosterone Fluid Intake or blood solute concentration ADH released from P. Pituitary H20 reabsorbed in distal tubule Urine output Fluid Intake or blood solute concentration ADH is suppressed and distal tubule becomes impermeable to water urine output When Aldosterone is released from Adrenal Cortex sodium and water reabsorbed blood volume urine output

Collecting Duct once urine is formed in the kidneys it moves into collecting ducts into calyces of the renal pelvis and from there into the ureter

Process of Urine Formation

1. Glomerular Filtration (In Glomerulus and Bowmans Capsule)

2.

Blood enters glomerular capillaries and filtered in ff ways: Plasma proteins and RBCs are too large and cant pass capillaries out of glomerulus and into capsule, and stays in the bloodstream All other plasma constituents pass thru capillaries out of glomerulus and into capsule and becomes the Glomerular Filtrate Glomerular Filtration Rate (GFR) : 25 mL /min; 180L /day As glomerular filtrate passes thru tubules, substances that body wants to retain are reabsorbed Such as water, electrolytes (Na,K, bicarbonate), glucose and amino acids 99% of the Glomerular filtrate is reabsorbed by tubules and the remaining 1% is not reabsorbed and forms the URINE

Tubular Reabsorption

3.

Tubular Secretion

Tubules secrete some substances into the Glomerular filtrate to remove them from the body o Hydrogen Ions, Potassium Ions, Ammonia (Urea), Creatinine (end product of muscle metabolism), uric acid (end product of nucleic acids metabolism) Ureters Two tubular structures attached to each kidney which carry urine from kidneys into the bladder Length: 25 30cm (10 12 inches long in the Adult) At the junction between ureter & bladder, a small, flap like fold of mucous membrane act as a valve to prevent urinary reflux (backflow) of urine up to ureters Urinary Bladder Hollow, distendable, muscular organ that serves as reservoir for urine Normal Bladder Capacity: 300 600 mL When empty it lies behind symphisis pubis When full, may extend above symphisis pubis; in extreme situations, may extend to umbilicus Has three parts 1. Detrusor Muscle o A layer of smooth muscle fibers that allows bladder to expand as it fills with urine and to contract to release urine during voiding. o Layers: longitudinal or lengthwise, oblique, circular 2. Trigone triangle area located at the base of bladder 3. Internal Urinary Sphincter involuntary control; located at the base of bladder Urethra Extends from the bladder to the urinary meatus (opening) Located between the labia majora, in front of vagina, below clitoris Serves as passageway for the elimination of urine External Urinary Sphincter voluntary control; located at the base of urethra Criteria Length Males 20 cm ( 8 inches) LONGER Females Between 3 4 cm(1.5 inches ) SHORTER Women are prone to UTI because of their shorter urethra and proximity of urinary meatus to the vagina and anus Passageway for the elimination of urine

Function

Passageway of urine and semen Has 3 regions prostatic membraneous spongy or cavernous

Pelvic Floor Vagina, rectum, and urethra pass thru the pelvic floor which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis

PROCESS OF URINARY ELIMINATION / MICTURITION/ VOIDING Process of emptying the urinary bladder 1. Urine collects into the bladder until pressure of that amount of urine stimulates sensory nerve fibers in Detrusor muscle called STRETCH RECEPTORS o This occurs when adult bladder contains 250 450 mL of urine o Children 50 to 200 mL of urine 2. Stretch Receptors transmit impulses to spinal cord at the voiding reflex center located at 2nd 4th sacral vertebrae causing the internal sphincter to relax and stimulate the urge to void 3. If the time and place are appropriate for urination, the conscious portion of brain relaxes the external urinary sphincter muscle and urination takes place. 4. If the time and place are not appropriate, the micturition reflex usually subsides until bladder becomes more filled and reflex is stimulated again. Note: Voluntary control of urination is possible if the nerves supplying the bladder and urethra, the neural tracts of the cord and brain, and motor area of cerebrum are all intact. Injury to any of these (ex. Cerebral Hemmorhage or Spinal Cord Injury above the level of sacral region) results in intermittent involuntarily emptying of bladder. FACTORS AFFECTING VOIDING / URINARY ELIMINATION I. Developmental Factors (Age) a. Infants Urine output varies according to fluid intake but gradually increases to 250 500 ml/day during the 1st year. Infant may urinate up to 20x per day Characteristics of urine: colourless, odourless, specific gravity of 1.008 Kidneys are immature thus unable to concentrate urine well. Born without urinary control but develops between 2 5 y/o Control during the day normally precedes night time control b. Presechoolers Can take responsibility for independent toileting Often forget to wash hands & flush the toilet and need instruction in wiping themselves Teach girls to wipe from front to back to prevent contamination of feces c. School Age Elimination system reaches maturity, kidneys double in size between 5 10 y/o May void 6 8x a day Enuresis involuntary passing of urine when control should be re-established (about 5y/o) Nocturnal Enuresis (Bed Wetting) Involuntarily passing of urine during sleep that usually occurs b/c of failure to awaken when bladder empties. Not considered a problem until after age of 6. a. Primary Enuresis child has never achieved night time urinary control b. Secondary Enuresis child has achieved dryness for 6 consecutive months; often r/t to constipation, stress, or illness and may resolve when cause is eliminated. c. Both Primary and Secondary may be both related to poor daytime voiding habits.

Desire to control daytime urinary elimination occurs when child becomes aware of the ff (usually around 2 y/o) 1. Discomfort of a wet diaper 2. Sensation that indicates need for urine elimination Nurses can be involved in a childs toilet training in the ff ways: 1. Clothes that can be removed independently 2. Personal toilet seat 3. Sufficient time to eliminate urine 4. Consistent, relaxed atmosphere 5. Praise for successful behaviour while avoiding punishment for unsuccessful behaviour 6. Non stressful period in which to initiate toilet training d. ELDERS Excretory function of kidney diminishes, but not below normal levels unless disease process intervenes. Nephrons impairing kidneys filtering abilities Kidney function risk for toxicity from medications if excretion rates are longer. Urinary Urgency and Urinary Frequency are common. a. Men often due to enlargement of prostate gland b. Women d/t weakened muscles supporting bladder or weakness of urethral sphincter The capacity of bladder to completely empty diminish with age. This explains why the need for elders to arise at night to void (Nocturnal Frequency) and Retention of Residual Urine Changes that can affect urinary elimination include the ff: 1. number, size, weight, and function of nephrons and size and weight of kidney 2. renal blood flow and consequently, GFR 3. reabsorptive and secretory capabilities of tubules and consequently, ability to empty bladder without leaving residual urine (urine that was left) and difficulty starting urinary stream 4. innervations of detrusor muscle & external urinary sphincter and consequently, ability to maintain urinary incontinence II. Psychosocial Factors Privacy, Normal Position, Sufficient Time, and occasionally running water help stimulate micturition reflex. Voluntarily suppression of urination because of perceived time pressures can increase risk for UTI (ex. Nurse often ignore to void until they are able to take a break) III. Food and Fluid Intake Increased fluid intake urine production and elimination by INHIBITING the release of ADH which inhibits reabsorption of water. Decreased fluid intake urine production and elimination by FACILITATING the release of ADH which facilitates reabsorption of water. Intake of certain types of fluids can adversely affect urinary elimination Alcohol and Caffeine urine production and elimination Fluid containing Sodium urine production and elimination Increase in urine production and elimination if high in fluid content Fruits, Vegetables, Cooked Cereals

Decrease urine production and elimination if high in sodium content Potato Chips, cheese, pickles Changes the color of urine Beets and blackberries turns urine RED Carrot (beta-carotene) turns urine YELLOW than usual.

IV. MEDICATIONS Medication Diuretics (Thiazide / Loop) Mechanism of Action Increases urine formation by preventing reabsorption of sodium, water, and electrolytes from kidney tubules Examples Chlorothiazide (Diuril) Hydrocholorothiazide (HydroDiuril) Furosemide (Lasix) Loop Spironolactone (Aldactone) Triamterene (Dyrenium) Bethanechol Chloride (Urecholine) Atropine Sulfate Buscopan (Hyoscine) Morphine Sulfate Meperidine HCL (Demerol) Codeine Hydromorphone (Dilaudid) Phenithiazines MAO Inhibitors Pseudoephedrine (Actifed and Sudafed) Hydralazine (Apresoline) Methyldopate (Aldomet) Levodopa Trihexyphenidyl (Artane) Benztropine (Cogentin) Propranolol (Inderal)

Cholinergics Anticholinergics Opiod Analgesics

Stimulate contractions of detrusor muscle that facilitates urinary elimination Inhibit bladder contraction & detrusor muscle which lead to urinary retention Suppress awareness of bladder distention which lead to urinary retention

Antidepressants Antipsychotic agents Antihistamines Antihypertensives Antiparkinsonism

Urinary retention

Urinary retention Urinary retention Urinary retention

Beta Adregernic Blockers

Urinary retention

Can change the color of urine 1. Red - Methyldopa (Aldomet) 2. Orange, Orange Red, or Pink Phenazopyridine (Pyridium) Phenytoin (Dilantin) 3. Green or Blue Green Amitriptyline (ELavil) Indomethacin (Indocin) B Complex Vitamins

Rifampin (Rifadin) Warfarin Sodium (Coumadin)

4. Brown or Black Levadopa (L-Dopa) Iron Preparations a. Ferrous Sulphate (Feosal) b. Ferrous Gluconate (Fergon) Ferrous Fumarate (Feostat) V. ACTIVITY Inadequate activity can affect urinary elimination tone of abdominal muscles results to amount of intra- abdominal pressure that can be exerted on detrusor muscle during voiding. tone of pelvic floor muscles which can result in a ability of external urinary sphincter to hold back the flow of urine when placed under pressure VI. PSYCHOLOGIC FACTORS Anxiety or Stress sympathetic portion of ANS inhibits detrusor muscle contractions and increases tone of internal urinary sphincter which can lead to URINARY RETENTION. VII. LIFESTYLE Delayed voiding can stretch and weaken detrusor muscle and lead to incomplete emptying of bladder, residual urine left in bladder, and bladder infections such as the ff: o Ignoring urge to void (insufficient time, unavailable toilet facilities, and lack of privacy) o Inability to assume normal position VIII. PATHOLOGIC CONDITIONS a. Decrease or eliminate innervations of detrusor muscle and internal and external urinary sphincter which can lead to URINARY INCONTINENCE Spinal Cord Injury CVA Multiple Sclerosis b. Decrease physical mobility and ability to reach a toilet or commode in time/or assume a normal position for voiding Rheumatoid Arthitis Degenerative Joint Disease Multiple Sclerosis c. Decrease Cognitive Ability CVA Alzheimers Disease Parkinsons Disease d. Alteration of the RELEASE OF HORMONES SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH) inappropriate release of ADH and decreased urine prod and elimination; urinary retention DIABETES INSIPIDUS inhibits release of ADH and increase urine prod and elimination ALDOSTARONISM excessive ALDOSTERONE and decreased urine prod and elimination e. Decreased in the blood supply to the kidney, GFR, and Urine Prod and Elimination Arteriosclerosis Shock

 f.

Massive Diarrhea Vomiting and Dehydration

Obstruct the flow of urine which can result in urinary retention Strictures of Ureters and Urethra Benign Prostatic Hypertrophy Urinary Tumors that press against urinary tract and calculi

g. Alter the cellular structure and function of kidney Polycystic Kidney Disease Acute Glumerolonephritis Renal Tuberculosis h. Increase core body temp and BMR which may result in sweating, insensible water loss, and decreases urine prod and elimination Significant Infectious Process Head Injury Burns VIII. DIAGNOSTIC PROCEDURE CYSTOSCOPY - Precipitate urethral edema w/c may obstruct urine flow = Urinary Retention IX. ANESTHESIA AND SURGERY 1. General, Spinal, and Epidural Anesthesia can affect urinary elimination: Decreases BP, GFR, and urine prod and elimination 2. Surgery on any part of Intestines and Genitourinary System can affect urinary elimination Edema and or bleeding which may obstruct flow of urine resulting in Urinary Retention Negative Imbalance between IV fluid intake and blood loss which can result in decreased BP, GFR, and consequently, urine production and elimination Release of ADH as part of stress response. COMMON ALTERATIONS IN URINARY PRODUCTION AND ELIMINATION Altered Urine Production Polyuria or Diuresis Abnormally large amounts of urine Can follow excessive fluid intake called Polydipsia SELECTED ASSOCIATED FACTORS Caffeine or alcohol Diuretics Presence of thirst, dehydration, and weigh loss DM, Diabetes Insipidus, Kidney Disease

Oliguria Decreased fluid intake Low urine output usually <500 ml in 24 Dehydration or <30 ml per for adult Hypotension, shock, heart failure Anuria History of kidney disease Renal Failure (elevated BUN and Serum Lack of urine production Creatinine, Edema, and Hypertension) Voiding <100 ml in 24 Altered Urinary Elimination Selected Associated Factors Frequency Pregnancy Voiding at frequent intervals Increase Fluid Intake > 5 6x per day UTI Nocturia Voiding 2 or more times at night

Urgency Sudden strong desire to void May or may not pass a lot of urine Dysuria Voiding that is either painful or difficult

Psychologic Stress UTI UTI, inflammation, injury Hesitancy (delayed &difficult in initiating voiding) Hematuria, Pyuria (pus in urine), & frequency Family History of Enuresis Difficult access to toilet Home Stresses

Enuresis Involuntary urination in children beyond the age when bladder control is normally acquired (usually 4 or 5 y/o) Nocturnal Enuresis (Night) irregular in occurrence and affects boys more than girls Diurnal (Daytime) Persistent and pathologic in origin. Affects women and girls more frequently Urinary Incontinence Involuntary urination a symptom not a disease Related Factors (Etiology) Altered Environment Sensory, Cognitive, or Mobility Defects Interventions Incontinence pads or pants during the day Clothes that are quick to remove Provide means for summoning assistance Provide cues that mark the bathroom Remove obstacles to the bathroom Provide proper receptacle for urine Toilet every 3 hours Catheterize only if bladder training falls Limit use of coffee, tea, alcohol Encourage fluid intake of 1500 2000 ml per day Regulates fluid intake at prescheduled times to promote predicatable voiding Restrict fluids 2 3 hours before bedtime

Bladder inflammation or other disease Mobility impairment Leakage when coughing, laughing, sneezing Cognitive impairment Common Causes o UTI o Urethritis inflammation of urethra o Pregnancy o Hypercalcemia high calcium in blood o Volume overload o Delirium o Stool Impaction o Psychologic Factors Types: 1. Reflex Incontinence involuntary passage of urine at somewhat predictable intervals when specific bladder volume is reached
2.

Stress Incontinence involuntary passage of urine <50ml occurring with increased intaabdominal pressure Urge Incontinence involuntary passage of urine after a strong sense of urgency to void

3.

Urinary Rentention Incomplete or Impaired emptying of bladder, urine accumulates & bladder becomes distended Related Factors 1. Obstruction of urine flow prostate gland enlargement fecal impaction pregnancy urethral stricture urethral edema esp after childbirth cystography and urethrocystography 2. Alterations in motor or sensory innervations to detrusor muscle and internal urinary sphincter spinal cord injury peripheral nerve trauma degeneration of peripheral nerves 3. Inability to relax Internal Urinary Sphincter emotions, stress, anxiety muscle tension 4. Use of medications w/ retention as adverse response Defining Characteristics 1. Absence of UO over several hours 2. Distended Bladder (2000 3000ml) 3. Sensation of pressure, discomfort, tenderness over symphisis pubis 4. Overflow incontinence URINARY TRACT INFECTION Infection of a structure in urinary tract Related Factors 1. Indwelling Urinary Catheters 2. Bladder Distentions 3. Shorter Urethra in Women 4. Obstruction of urine flow resulting in Urinary Stasis 5. Poor Perineal Hygiene 6. Urinary PH (most bacteria grow more in alkaline urine, less in acidic urine) Defining Characteristics 1. Dysuria, Urgency, Frequency 2. Fever or Chills 3. Nausea and Vomiting 4. Malaise 5. Hematuria (blood in urine) 6. Flank Pain (costovertebral tenderness)

Distended bladder - palpation & percussion Associated Signs: Pubic discomfort, restlessness, frequency, & small UO Recent Anesthesia Recent Perineal Surgery Presence of Perineal Swelling Medications prescribed Lack of privacy

Interventions 1. Help client to assume normal position to void 2. Stimulate reflex voiding center Running water stroking inner thighs 3. Remove blockage if possible vaginal or rectal packing fecal impaction 4. Catheterize intermittent or indwelling urinary catheter to resolve acute retention 5. Perform CREDES MANEUVER Manual pressure on bladder to promote emptying just above symphisis pubis

Interventions 1. Encourage 1500 2000 ml of fluids daily 2. Decrease Urinary ph (acidify urine) o Meats, Eggs, Cranberries, Prunes, Plums 3. Urinary Tract Microbials as prescribed a. Sulfonamides Sulfamethoxazole (Bactrim, Septra) Sulfisoxasole (Gantrisin) b. Urinary Tract Antiseptics Cinoxacin (Cinobac) fluoroquinolones Methenamine Mandelate (Mandelamine) c. d. Monobactam and Fluorquinolones Azetreonam (Axactam) Ciprofloxacin (Cipro) Urinary Tract Analgesic Phenazopyridine (Pyridium)

NEUROGENIC BLADDER Client doesnt perceive bladder fullness and unable to controle urinary sphincters. Bladder may become flaccid and distended or spastic with frequent involuntary urination NURSING MANAGEMENT ASSESSMENT 1. Nursing History Normal voiding pattern, frequency, appearance of urine, recent changes, past or current problems with urination 2. Physical assessment of Genitourinary System, Hydration Status, and Urine Examination Inspect, Palpate, and Percuss Bladder Inspect Meatus for swelling, discharge, and inflammation Assess skin color, texture, tissue turgor, and presence of edema If incontinence, dysuria is noted in history, inspect skin of perineum for irritation. 3. Relate the data obtained to the results of any diagnostic tests and procedures Characteristics of Normal and Abnormal Urine
Characteristics Amount in 24 hours Color, Clarity Normal 1,200 1,500 ml Abnormal <1,200 and >1,500 Nsg. Consideration Intake = Output Output <30ml/ may indicate decrease blood flow to kidneys Concentrated urine is darker in color. Diluted urine - almost clear or very pale yellow. Some foods and drugs may color urine Hematuria (pink, bright red, or rusty brown) Mens can also color urine but shouldnt be confused with hematuria. WBCS, pus, bacteria, or contaminants such as prostatic fluid, sperm / vaginal discharge may cause cloudy urine Some foods cause a musty odor (Asparagus) Infected urine - fetid odor Urine high in glucose sweet odor Urine in the bladder is sterile Urine specimens may be contaminated with bacteria from perineum during collection Freshly voided urine is somewhat acidic Alkaline urine (high ph) may indicate UTI Acidic urine (low ph) is found in salivation, diarrhea, or diet high in protein Concentrated urine has specific gravity. Diluted urine has low specific gravity Glucose indicates glucose level (>180mg/dl); may indicate of undiagnosed or uncontrolled DM KETONES end product of breakdown of fatty acids are not present in urine. May be present with clients who have DM, state of salivation, or who ingested excessive amounts of aspirin UTI, kidney disease, bleeding from urinary tract

Straw, Amber Transparent

Dark amber, cloudy, dark orange, red or dark brown, mucus plugs, viscid, thick

Odor

Faint, aromatic

Offensive

Sterility

No microbes

Microbes present

pH

4.5 8

<4.5 and >8

Specific Gravity Glucose

1.010 1.025 Not present

<1.010 >1.025 Present

Ketone Bodies (Acetone)

Not present

Present

Blood

Not present

Occult (microscopic) Slight Red

Steps in Measuring Urine Output 1. Wear clean gloves to prevent contact with microbes or blood in urine 2. Ask client to void in a clean urinal, bedpan, commode or toilet collection device 3. Instruct client to separate urine from feces & avoid putting toilet paper in urine container. 4. Hold container at eye level and read amount (has measuring scale) 5. Record amount on fluid I&O sheet 6. Rinse urine collection and measuring containers with cool water and store appropriately 7. Calculate & document total output at the end of each shift and at the end of 24 hours on the Clients chart Measuring Residual Urine Residual urine is the urine remaining in the bladder following voiding. Normally 50 100mL 1. Catheterize or bladder scans the client after voiding 2. Amt of urine voided and amount obtained from bladder scan are measured and recorded 3. Indwelling urinary catheter may be inserted if residual urine exceeds a specified amount DIAGNOSTIC TESTS 1. BLOOD TESTS a. Blood Urea Nitrogen (BUN) Made up of urea, the end product of protein metabolism by the liver is measured. NR: 10 20 mg/dl (3.6 7.2 mmol/L) b. Serum Creatinine Measures the end product of muscle metabolism NR Females (0.5 1.1 mg/dl) NR Males (0.6 1.2 mg/dl) 2. URINE TESTS a. Routine Urinalysis Collection of voided, clean catch, or catheterized specimen of urine to ascertain the presence of normal or abnormal constituents of urine. b. Urine for Culture and Sensitivity Collection of clean catch or catheterized urine specimen to ascertain the no. and types of pathogens in urine c. Composite Urine Collection Collection of all voided or catheterized urine for specific no. of hours (usually 2 24) to perform quantitative and qualitative analysis of one or more substances in the urine. d. Creatinine Clearance Test 24urine and and serum creatinine levels to determine GFR to identify renal function. Formula: C= (U x V) P C = clearance rate U = creatinine in urine (mg/dl) V = volume of urine (ml/24 hours) P = creatinine in plasma (mg/dl) Normal: Females (85 125 ml/min) Males (95 135 ml/min) e. Urinary Electrolytes Collection of voided, clean catch, or catheterized urine specimen to ascertain amount of various electrolytes in urine. f. Urine Osmolarity Collection of voided, clean catch, or catheterized urine specimen to ascertain the concentration of plasma in solution in the urine Normal: 300 1200 mOsm/L

3. Direct Visualization Cystoscopy and Cystourethroscopy- Insertion of scope(s) (cytoscope and/or urethroscope) into urethra and bladder to directly visualize urethra and bladder 4. Indirect Visualization a. Kidneys, Ureters, Bladder (KUB) Plain radiograph of abdomen to determine gross anatomic features and/or abnormalities of kidneys, ureters, and bladder. b. Intavenous Pyelogram (Excretory Urography) Injection of radiopaque contrast medium into a vein, which is rapidly carried by blood into renal vasculature, filtered by glomeruli and excreted urine, to determine gross anatomic features and/or abnormalities of the kidneys, ureters, and bladder. c. Nephrotomography Sectional radiographs that provide images of kidneys in different planes to provide info about gross anatomic features and/or abnormalities of the kidneys d. Computed Tomography (CT SCAN) Provide 3D info about gross anatomic features and/or abnormalities of kidneys, ureters, and bladder. e. Cystography and Cysturethrography Installation of radiopaque contrast medium thru urethral catheter to detect gross anatomic features and/or abnormalities of bladder f. Renal Arteriography Instillation of radiopaque contrast medium into an artery (usually femoral) to assess Arterial Blood Supply to kidneys g. Percuatenous Renal Biopsy Insertion of trocar thru the skin into renal capsule and then passing a biopsy needle thru trocar to obtain tissue specimen to assess abnormalities of renal cell structure h. Renography (Kidney Scan) Injection of radionuclide medium into a vein and monitoring its uptake in the kidneys to provide gross info about renal blood flow, structure, and function i. Ultrasonography Use of sound waves transmitted thru skin to determine gross anatomic features and /or abnormalities of the kidneys, ureters, and bladder. NURSING DIAGNOSES 1. Impaired Urinary Elimination: dysfunctional in urine elimination 2. Functional Urinary Incontinence inability of usually continent person to reach toilet in time to avoid unintentional loss of urine 3. Reflex Urinary Incontinence involuntary loss of urine @ somewhat predictable intervals when a specific blader volume is reached 4. Stress Urinary Incontinence sudden leakage of urine occurring with activities that increases abdominal pressure 5. Total Urinary Incontinence continuous and unpredictable passage of urine 6. Urge Urinary Incontinence involuntary passage of urine occurring soon after a strong sense of urgency to void 7. Overflow Urinary Incontinence 8. Urinary Retention

Problems of Urinary Elimination also may become the Etiology for other problems 1. Risk for Infection client has urinary retention or undergoes invasive procedures such as catheterization or cystoscopic exa 2. Low Self Esteem or Social Isolation if the client is incontinent. Incontinence can be physically or emotionally distressing b/c it is considered socially unacceptable. Client is embarrassed about dribbling or having an accident and may restrict normal activities for this reason. 3. Risk for Impaired Skin Integrity if client is incontinent. Bed linens and clothes saturated with urine irritate and macerate skin. Prolonged Skin dampness leads to dermatitis (inflammation of skin) and subsequent formation of dermal ulcers. 4. Self Care Deficit toileting if the client has functional incontinence 5. Risk for Deficit Fluid Volume or Excess Fluid Volume if client has impaired urinary function associated with disease process 6. Disturbed Body Image if client has urinary diversion ostomy 7. Deficient Knowledge if client requires self - care to manage 8. Risk for Caregiver Role Strain client is incontinent & being cared by a family member for extended periods 9. Risk for Social Isolation if the client is incontinent. PLANNING 1. Maintain or Restore normal voiding pattern 2. Regain Normal Urine Output 3. Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self- esteem 4. Perform toilet activities independently with or w/o assistive devices 5. Contain urine with appropriate device, catheter, ostomy appliance, or absorbent product IMPLEMENTING 1. Maintain Normal Urinary Elimination a. Promote Fluid Intake b. Maintain Normal Voiding Habits c. Assist with Toileting (ex. client weakened with a disease process or physically impaired; may provide urinary equipment such as bedpan/urinal/commode. 2. Prevent Urinary Tract Infections a. Drink 80z of water daily to flush bacteria out of the urinary system b. Practice frequent voiding (every 2- 4 hrs) to flush out bacteria and prevent micbrobes ascending to bladder. Void asap after intercourse c. Avoid harsh soaps, bubble bath, powder, sprays in perineal area for it may cause irritation d. Avoid tight fitting pants e. Wear cotton rather than nylon underwear f. Proper Perineal Hygiene (front to back) g. If recurrent UTI, take a shower than baths. Bacteria present in bathwater can enter urethra h. Increase Urine Acidity. Ingest VITAMIN C and drink 2 3 glasses of CRANBERRY JUICE daily. 3. Managing Urinary Incontinence a. Continence (Bladder) Training requires involvement of client, nurse, and support persons * Bladder Training requires that the client postpone voiding , resist or inhibit sensation of urgency and void according to timetable rather than the urge to void. * Habit Training timed voiding or scheduled toileting. * Prompted Voiding encourages the client to use the toilet and reminding client when to void.

b. Pelvic Muscle Exercises (PME) or Kegels Exercises Helps strengthen pelvic floor muscles and reduce incidence of incontinence by stopping urination midstream or tightening the anal sphincter as if to hold a bowel movement. 4. Maintain Skin Integrity 5. Apply External Urinary Drainage Devices - use of condom or external urinary catheter Managing Urinary Retention 1. Credes Maneuver manual pressure on bladder to promote bladder emptying; not advised without a physician or nurse; used only for clients who have lost and are not expected to regain voluntary bladder control. When all measures fail, urinary catheterization may be necessary.

Urinary Catheterization
Introduction of catheter into Urinary bladder and performed only when necessary STRICT STERILE TECHNIQUE One of the most common causes is Nosocomial Infections Made of rubber or plastics although may be made from latex, silicone, polyvinyl chloride (PVC) Sized by the diameter of lumen using French (Fr) Scale: THE LARGER THE NUMBER, THE LARGER THE LUMEN. Straight catheters inserted to drain bladder and then immediately removed Retention catheters, which may remain in bladder to drain urine may be used.

Straight Catheter
Single lumen tube with a small 1 cm opening. Coude Catheter is the variation of straight catheter. It has tapered, curved tip makes it easier to pass through curvature of prostatic urethra (used for men with Prostatic Hypertrophy b/c it is easily controlled and less traumatic on insertion)

Straight Catheter

Coude Catheter

Foley / Retention / or Indwelling Urinary Catheter

Double Lumen o Larger lumen - drains urine from bladder o Smaller lumen - used to inflate balloon with sterile water to hold it in place within bladder o Balloons are sized by the volume of sterile water used to inflate them (sizes 10ml & 30ml). Size of balloon is indicated on the catheter along with the diameter (ex. #18 FR 10 mL) Usually are connected to a closed gravity drainage system that consists of catheter, drainage, and collecting bag for urine. This reduces risk of microbes to enter urinary system.

3 Way Foley Catheters

Has a 3rd lumen thru which sterile irrigation fluid can flow into the bladder. First lumen - drains urine through the catheter into a collection bag. Second lumen holds sterile water when catheter is inflated and used to deflate the balloon. Third lumen instill medications into bladder; provide route for continuous bladder irrigation.

Emptying the Bag The large drainage bag must be emptied at least every 8 hours even if it is not full. If the bag is small and fills quickly, it should be emptied when the bag is 2/3 full. When emptying the bag, be careful not to touch the top of the spout to the container into which it is being drained. Also, dont touch top of the spout with your hands. Changing the Bag 1. Wash your hands with soap and water. 2. Disconnect the tubing from the catheter. Insert the new drainage bag tubing into the catheter. 3. If you are going to reuse the bag you just switched from, the connection site must be covered with a sterile cap or gauze. The bag must be kept in a clean place. Tips Keep the drainage system below the level of the bladder so the urine does not back up. The leg bag will allow you to wear regular clothes and be free to play or work. Remember that because it is small, it will need to be emptied often. Be sure there are no kinks or bends in the tubing. Urine will not drain if this happens. If the patient's drainage bag becomes dirty or foul-smelling, it needs to be changed. If a hole is punctured in the bag or tubing, it also needs to be changed. Make sure the patient drinks plenty of fluids. The urine should be light yellow and clear.