Maintaining Normal Urination

Maintaining Normal Urination

A. pt education focus on pt's specific clinical problem

1. teach about proper hygiene to prevent infections when giving bath

2. teach pt early symptoms of urinary alterations

3. incorporate teaching when giving meds or administering fluids (talk about increasing

fluid intake)

B. promoting normal micturition maintain normal elimination

1. nurse can teach pt to relax to void. sit or squat, raise head of bed, assume normal position

2.sound of running water can help

3. stroke inner aspect of thigh stimulates sensory nerve & promotes urination

4. pouring water over perineum can create sensation to urinate

C. maintain elimination habits

1. post childbirth should urinate within 4 hrs.

2. prevent urinary stasis, incontinence

D. maintain adequate fluid intake a pt with normal renal function without heart, kidney

problems 2000-2500mL /day is good

1. an average of 1200-1500 mL is usually sufficient unless history of UTI

2. when fluid intake is increased, excreted urine flushes out solutes or particles that may

collect in urinary system

E. Preventing infection good perineal hygiene & adequate fluid intake, wipe front to back,

F. Acidifying urine inhibit microbial growth

1. meats, eggs, whole grain breads, prunes

2. cranberry juice & ascorbic acid lower pH

VIX. Medications

A. meds that are given for incontinence caused by bladder irritation: anticholinergics

1. the drugs depress the neurotransmitter acetylcholine which stimulates bladder ie.

Opropantheline, Oxybutenine chloride, Digipan

2. these meds can cause cardiac dysrhythmias not use on cardiac pts. anticholinergics can

cause constipation & dry mouth

B. When the bladder empties, detrusor muscle contracts in response to parasympathetic

stimulation

1. incomplete bladder emptying results from impaired enervation or weakness of detrusor

2. pt. experiences retention & overflow incontinence

3. cholinergic drugs increase contraction of the bladder

4. Bethanechol (Urecholine)

C. the dribbling or overflow incontinence seen in men with prostatic enlargement

1. Terazosin is given daily

2. It can also cause

X. Many falls in older adult make sure pathways clear

some meds cause transient hypotension

Identify all of pt's prescription drugs

Identify all of pt's prescription drugs

1. how long taking? any changes?

2. drugs for diabetes mellitus, hypertension, cardiac disorders, hormonal disorders, cancer,

arthritis, psychiatric disorders, potential causes of renal dysfunction

D. Any over the counter drugs or herbal supplements laxatives, analgesics, NSAID's,

St. John's Wort

E. Ask the pt about chemical exposures at the work place, exposure to hydrocarbons, heavy

metals, Pb, mercury, Cl gas.

F. Ask the pt about any protein / albumen in urine, any BP meds, any high BP readings

VI. Physical Assessment

A. skin & mucosal membranes turgor (hydration), urinary incontinence skin breakdown

B. kidneys infected / inflamed flank or back pain nurse assesses for tenderness

costo-vertebral angle (spine & 12^th rib) LeMone

C. bladder -on inspection the nurse may note swelling or convex curviture of lower abdomen -

using light palpation, partially filled bladder is smooth rounded when apply pressure pt can

feel pain, tenderness, urge to urinate.

D. Urethra meatus inspect for discharge, inflammation & lesions

VII. Common types of Urinary alterations

A. Urgency feel need to void full bladder, irritation, inflammation from infection,

noncompliant urethra, sphincter, or psychological stress

B. dysuria difficult / painful urination (trauma inflammation of urethral sphincter

C. frequency interval 2hrs. - increased fluid intake, bladder inflammation, bladder

pressure, pregnancy, psychological stress

D. Hesitancy difficulty in initiating urination prostate enlargement, anxiety, urethral edema

E. Polyuria void large amounts urine or frequent excess fluid intake, diabetes mellitus, diabetes

insipidus (low ADH or reduced sensitivity to ADH.

F. Oliguria diminished urinary output relative to intake, kidney function (30 mL/hr) need at least

240 mL/day. factors dehydration, renal failure, UTI, increased ADH, CHF

G. nocturia frequent night urination excessive fluid intake before bedtime. esp. caffeine,

alcohol, renal disease, aging, prostate enlargement

H. dribbling leakage of urine despite voluntary control of urination stress, incontinence,

overflow from urinary retention

I. Incontinence involuntary loss of urine multiple factors unstable urethra, loss of pelvic

muscle tone, estrogen depletion, fecal impaction, neurological impairment

J. hematuria blood in urine neoplasms of kidney or bladder, glomerular disease, infection of

kidney, bladder, trauma, calculi, stones, bleeding disorder (hemophilia)

K. retention accumulation of urine in bladder (100mL) inability to empty fully obstruction,

bladder inflammation, decreased sensory activity, necrogenic bladder, prostate enlargement,

post-anesthesia effect, side effect of meds, (anticholinergic, antidepressants)

Review diagnostic test in LeMone

Identify all of pt's prescription drugs

Identify all of pt's prescription drugs

1. how long taking? any changes?

2. drugs for diabetes mellitus, hypertension, cardiac disorders, hormonal disorders, cancer,

arthritis, psychiatric disorders, potential causes of renal dysfunction

D. Any over the counter drugs or herbal supplements laxatives, analgesics, NSAID's,

St. John's Wort

E. Ask the pt about chemical exposures at the work place, exposure to hydrocarbons, heavy

metals, Pb, mercury, Cl gas.

F. Ask the pt about any protein / albumen in urine, any BP meds, any high BP readings

VI. Physical Assessment

A. skin & mucosal membranes turgor (hydration), urinary incontinence skin breakdown

B. kidneys infected / inflamed flank or back pain nurse assesses for tenderness

costo-vertebral angle (spine & 12^th rib) LeMone

C. bladder -on inspection the nurse may note swelling or convex curviture of lower abdomen -

using light palpation, partially filled bladder is smooth rounded when apply pressure pt can

feel pain, tenderness, urge to urinate.

D. Urethra meatus inspect for discharge, inflammation & lesions

VII. Common types of Urinary alterations

A. Urgency feel need to void full bladder, irritation, inflammation from infection,

noncompliant urethra, sphincter, or psychological stress

B. dysuria difficult / painful urination (trauma inflammation of urethral sphincter

C. frequency interval 2hrs. - increased fluid intake, bladder inflammation, bladder

pressure, pregnancy, psychological stress

D. Hesitancy difficulty in initiating urination prostate enlargement, anxiety, urethral edema

E. Polyuria void large amounts urine or frequent excess fluid intake, diabetes mellitus, diabetes

insipidus (low ADH or reduced sensitivity to ADH.

F. Oliguria diminished urinary output relative to intake, kidney function (30 mL/hr) need at least

240 mL/day. factors dehydration, renal failure, UTI, increased ADH, CHF

G. nocturia frequent night urination excessive fluid intake before bedtime. esp. caffeine,

alcohol, renal disease, aging, prostate enlargement

H. dribbling leakage of urine despite voluntary control of urination stress, incontinence,

overflow from urinary retention

I. Incontinence involuntary loss of urine multiple factors unstable urethra, loss of pelvic

muscle tone, estrogen depletion, fecal impaction, neurological impairment

J. hematuria blood in urine neoplasms of kidney or bladder, glomerular disease, infection of

kidney, bladder, trauma, calculi, stones, bleeding disorder (hemophilia)

K. retention accumulation of urine in bladder (100mL) inability to empty fully obstruction,

bladder inflammation, decreased sensory activity, necrogenic bladder, prostate enlargement,

post-anesthesia effect, side effect of meds, (anticholinergic, antidepressants)

Review diagnostic test in LeMone

Physiologic changes

Physiologic changes

A. Arteriosclerotic changes in renal arteries are most common form of vascular renal disease (BP)

increase in BP. These changes occur as part of aging process & degree of change depends on

specific arteries

affected & degree affected.

B. Aging is known to cause predictable increases in both sys. & dist. BP

1. this slow increase in BP begins early in life & continues through adulthood

2. untreated hypertension accelerates development of athlerosclerosis which can lead to kidney

failure

C. prostatic hypertrophy common physiologic change associated with age. untreated PH results in

urinary tract obstruction that can lead to kidney failure

D. aging women frequently develop problems with stress incontinence as muscles weakn & pelvic

organs put pressure on bladder & urethra (T pg 1489- 1490)

V. Health History

A. Nutrition / metabolic pattern

1. what is your typical daily food intake? describe days meals, snacks, vitamins, changes in diet

2 how much salt in food, salt substitute

3. how is your appetite?

4. fluid intake / day

5. what types of fluids do you drink?

6. how much fluid / day specific for yesterday?

7. Have you had any recent changes in weight?

8. changes in tightness in ring?

9. note any excessive intake or omissions of certain food

10.a high protein diet can result in temporary renal problems

11. clients at risk for calculi formation, avoid Ca (milk-containing foods), drink more water

12. ask about any changes in appetite or in the ability to discriminate tastes

13. symptoms can occur with accumulation of N waste products from renal failure (changes in

thirst can change urinary output

B. Elimination pattern (diabetes excessive thirst / urination)

1. what is your usual elimination pattern?

2. frequency, amount, color, odor, loss of control, nocturia

3. any previous renal or urologic problems? kidney stones?

Physiologic changes

Physiologic changes

A. Arteriosclerotic changes in renal arteries are most common form of vascular renal disease (BP)

increase in BP. These changes occur as part of aging process & degree of change depends on

specific arteries

affected & degree affected.

B. Aging is known to cause predictable increases in both sys. & dist. BP

1. this slow increase in BP begins early in life & continues through adulthood

2. untreated hypertension accelerates development of athlerosclerosis which can lead to kidney

failure

C. prostatic hypertrophy common physiologic change associated with age. untreated PH results in

urinary tract obstruction that can lead to kidney failure

D. aging women frequently develop problems with stress incontinence as muscles weakn & pelvic

organs put pressure on bladder & urethra (T pg 1489- 1490)

V. Health History

A. Nutrition / metabolic pattern

1. what is your typical daily food intake? describe days meals, snacks, vitamins, changes in diet

2 how much salt in food, salt substitute

3. how is your appetite?

4. fluid intake / day

5. what types of fluids do you drink?

6. how much fluid / day specific for yesterday?

7. Have you had any recent changes in weight?

8. changes in tightness in ring?

9. note any excessive intake or omissions of certain food

10.a high protein diet can result in temporary renal problems

11. clients at risk for calculi formation, avoid Ca (milk-containing foods), drink more water

12. ask about any changes in appetite or in the ability to discriminate tastes

13. symptoms can occur with accumulation of N waste products from renal failure (changes in

thirst can change urinary output

B. Elimination pattern (diabetes excessive thirst / urination)

1. what is your usual elimination pattern?

2. frequency, amount, color, odor, loss of control, nocturia

3. any previous renal or urologic problems? kidney stones?

ACE inhibitor (Angio I not converted to Angio II)

ACE inhibitor (Angio I not converted to Angio II)

1. this reduction of angio II decreases Aldosterone secretion & prevents Na & H₂O

retention

2. so ↓peripheral vascular resistance and ↓ BP

6. Excretion of metabolic wastes & toxins:

a. metabolic wastes excreted into glomerular filtrate

b. creatinine contained in the glomerular filtrate & excreted unchanged into urine

c. other wastes such as urea are excreted unchanged in the glomerular filtrate but are

unchanged in the glomerular filtrate but are resorbed in part during passage thru nephron

d. thus the amount of waste material excreted in urine is only a portion of which was

originally contained in glomerular filtrate

e. most drugs are either secreted by kidneys or metabolized by liver & secreted by kidneys

f. if kidneys are impaired, some drugs are contraindicated or have a "renal dose"

ie. 1. antibiotics (Vancomycin), 2. salicylates, 3. long-acting barbituates

III. Factors that can affect Micturition: (T- 1488)

A. food & fluid kidneys help maintain a careful balance of fluid intake & output should be

equal "I & O"B.

B.dehydration kidneys resorb fluid [urine]

C. foods that increase urine output caffeine, alcohol (inhibit ADH), watermelon (↑H₂O)

D. foods that decrease urine output salty, increase resorption / retention

E. foods that affect the smell of urine asparagus, onions

G. psychological some people are very private regarding elimination & have difficulty asking for

assistance stress can cause people to void small amount frequently. Perineal muscles & external

urethra sphincter to not relax, may not be able to void or completely empty

H. Activity & muscle tone regular exercise aids metabolism as well as optimal urine production

1. people who are bedridden or immobile for extended period of time can have poor urinary

control & urinary stasis

2. people who have a urinary catheter can lose bladder tone & can experience incontinence

when catheter removed

3. child birth ↓tone, ↓estrogen levels in menopause & damage to muscles

4. autonomic bladder flaccid bladder not controlled by brain due to injury, incontinence

Functions of the kidneys

Functions of the kidneys (LeMone)

1. water & electrolyte regulation

a. Bowman's capsule (ultrafiltrate) process by which the fluid part of urine is formed,

comes from plasma & flows into proxima convoluted tubule

b. Moves to the proximal convoluted tubule where most of the H2O, Na⁺ , Ca⁺⁺ , Cl⁺ , &

HCO₃ that were filtered out in capsule are resorbed into blood

c. Finally their concentration is adjusted in the distal nephron by hormones:

aldosterone produced by adrenal cortex

ADH (vasopressin) produced by hypothalamus & stored in pituitary. ADH released

when pt is bleeding or not taking in enough fluid.

d. Body waste products such as hydrogen ions, phosphate, & drugs & their metabolites are

secreted from blood in proximal tubules

2. Maintenance of Acid-Base balance

a. The respiratory system & kidneys work together to maintain ratio

b. The lungs vary the CO₂ content of the blood & kidneys principally secrete or retain

bicarb or H⁺ ions in response to blood pH

c. These two substances must move in or out of the blood at precisely the right time for

pH to remain stable

d. The exchange is accomplished in the proximal tubes & collecting ducts of the nephron

3. Erythropoiesis - kidney plays crucial role in RBC production

a. decreased tissue oxygenation stimulates special cells (peritubular capillaries) in kidneys

to produce 90% of body's erythropoietin

b. Erythropoietin stimulates the bone marrow to produce pro-erythroblasts which develop

into erythrocytes

c. Hypoxia & anemia generally trigger an ↑in production of erythrocytes

d. If a person has anemia secondary to chronic kidney failure then pt can receive

erythropoeitin "Epigen" or "Procrit" transfusion which can improve hematocrit & ↓

need for blood transfusion

4. Calcium & phosphorus regulation one of kidney's important functions

a. The kidneys influence reciprocal calcium & phosphorus balance by converting inactive

form of Vit. D. that is absorbed from gut to active form.

b. Parathyroid gland secretion of parathyroid hormone regulated by this form

of Vit. D & [Ca₂]

c. Under the influence of the parathyroid hormone, Ca₂ resorption ↑, phosphate

resorption ↓

5. Blood pressure regulation the kidneys play an active role in the regulation of BP,

primarily by plasma volume & vascular tone

a. blood pressure is manipulated through the kidney's response to several mechanisms that

alter total blood volume in circulatory system

b. These mechanisms include ADH response, the renin-angiotensin system, and aldosterone

response.

c. ADH release by the pituitary causes the kidneys to reabsorb water which is going to↑ BP

d. The renin-angiotensis & aldosterone response also influence regulation of BP

e. Renin is a hormone released by the juxtaglomerular apparatus of the nephron, in

response to Na & K depletion, a drop in renal artery BP or sympathetic stimulation

1. Renin stimulates the conversion of angiontensinogen (from liver) to angiotensin I

2. Conversion of angiotensin I to angiotensin II by angiotensin-converting enzyme from

lungs & produces powerful vasoconstriction & release of aldosterone result in ↑BP

3. Aldosterone is released from the adrenal glands & acts on kidney to resorb Na & H₂O

increasing circulatory blood volume & pressure

f. Prostaglandin & bradykinin, hormones produced by the kidney & other tissues, help

elevate BP & increase renal blood flow

1. they are released in response to renal ischemia, presence of ADH, Angio. II, &

sympathetic stimulation, they provide an immediate mechanism for improving blood

flow

g. Angiotensin-Converting Enzyme inhibitors angiotensin converting enzyme is blocked

Urinary Outline

Urinary Outline

I. Anatomy - Four urinary tract organs

1. kidney (1^° maintain homeostasis)

2. ureters

3. bladder

4. urethra

II. Physiology

A. Glomerular filtration is a passive, nonselective process in which hydrostatic pressure forces fluid

& solutes through a membrane

1. the amount of fluid filtered from the blood into capsule per min. - "glomerular filtration rate"

GFR is = 125 ml/min (GFR also called ultrafiltration rate)

2. three factors influence this:

a. body surface area

b. permeability of filtration membrane (glomerulus more efficient than other capillaries)

c. net filtration rate determined by hydrostatic pressure (push) & osmotic pressure (pull)

3. The osmotic pressure is coming from the glomerulus primarily the plasma proteins in the

glomerular blood & hydrostatic pressure is excreted by the fluids within Bowman's capsule

4. The difference between these two forces determines net filtration pressure which is directly

proportional to GFR.

5. Normal glomerular filtration rate in both kidneys is 120-125 mL/min

a. This rate is held constant under normal conditions by intrinsic controls called renal

autoregulation

1. when ↓BP, renal blood vessels dilate

2. when ↑BP, renal blood vessels constrict

b. These changes adjust the glomerular hydrostatic pressure & indirectly maintain GFR

B. The kidneys maintain a stable internal environment by balancing fluid / solute composition of

blood within narrow ranges three intricate processes are used:

1. Filtration refers to the movement of fluid across a semi-permeable membrane. This occurs

when plasma flows through glomerular capillary into Bowman's capsule as a result of

osmotic capillary pressures & capillary permeability

2. Resorption the movement of water & dissolved substances from tubular fluid (filtrate) back

into blood (occurs in tubules & collecting ducts)

3. Secretion the movement of fluid and substances from blood into tubular fluid (occurs in

tubules & collecting ducts)