Urinary Elmination

Kidneys- FILTER, Can live without one, but can function without both of them. Renal failure- kidneys lost their filtering ability. Nephron is where the filtering takes place inside the kidney Functional unit of kidney. Diuretics (Lasix) work in the loop of henley. Multiple factors that influence urination High blood pressure Accessibility Be in the right position Sitting or squatting Age Lose bladder tone Older population is at more risk of urinary retention Nocturia- up frequently during the night to urinate Diet Caffeine Alcohol Salt Retain water, decrease urine output Medication Socioeconomic factors Anxiety, privacy, emotions Surgical procedures General anesthetic Effects bowel and urine output Altered urinary elimination enuresis little urine output incontinence- no control over bladder stress incontinence most common interventions to help kingel exercise- strengthen pelvic floor neurogenic bladder occurs in patients who have a spinal cord injury Patients must straight cath themselves to prevent urinary retention Diuresis and polyuria mean the same Excessive urination Also see dehydration, polydipsia Oliguria Decreased urine output Anuria Less than 50 mL per day Input/output

0.05 mL per Kg per hour Diseases that cause damages to kidneys End stage renal disease IRREVERSIBLE damage to kidneys Dialysis patients do not have urine output Filters the blood Tests and diagnostic examinations Urinalysis Cheapest Checks ketones, glucose, WBCs (0-4 is normal, anything above 5 is abnormal.) Specific gravity, high means urine is concentration dehydrated. Culture and sensitivity (cns) will tell you what antibiotic the patient should be on. Must have an order to get this. Noninvasive Looking, observing Invasive examination Done under sedation Assessment of urine Intake and output Can be delegated to an unassisted personnel (CNA or PCT) Does not need an order to do this. Color Pale-straw to amber color Dark amber or orange dehydrated Cloudy infection Mucousindicates dehydration Clarity Transparent Odor Ammonia in nature is normal Abnormal is offensive in nature Assessing patients urinary system Must assess before you treat box 45.3 page 1137- questions to ask patient about urinary system asking about normal voiding patterns appearance of urine ask what is normal Any recent changes Past or current problems Any surgeries, dialysis Factors that influence elimination Physical assessment Percuss or palpate bladder.

Inspect urethral meatus for swelling, abnormal discharge (green, yellow, blood) and inflammation Skin color, texture, turgor Edema Assess intake and output Indwelling urinary catheters are the number one cause of UTIs 4.5-8 normal PH of urine Ketones are a by-product of fat breakdown. Ketones and glucose in urine indication DKA-diabetic ketoacidosis. How do you measure residual urine Straight cath, done after they void-invasive Bladder scan-not invasive so its better BUN(product of protein breakdown) and creatinine(by product of skeletal breakdown) These are done if suspected urinary issues Creatinine is more reliable BUN normal range Creatinine normal range 24 hour collection Void at 7am Collect all urine for 24 hours Keep in refrigerator or keep on ice After first void, do not flush the urine, no TP in the collection Best indicator, glomular filtration rate (GFR) Types of urinary incontinence Functional urinary incontinence-inability of usually continent pts to make it to the bathroom (urinate on self) (weak pelvic floor) Overflow- if bladder gets too full it could back up in to the ureters and up to kidneys. Reflex-somewhat predictable loss Stress urinary incontinence-sudden leakage of urine, cough, sneeze, jump. Reversible, bladder sling, kingels. Limit alcohol, coffee , evening fluid intake Planning Toileting schedule Bladder retraining Prevent skin breakdown Keep patients dry Teach patients how to wipe Front to back Take showers instead of baths Implementing Pelvic muscle exercises Tighten pelvic muscles Applying external urinary drainage devices (condom cath) Urinals Wear gloves

Sit patient up Privacy Make sure you hold it at eye level or put on a flat surface to get correct output amount. Dump it Put the urinal within reach of patient but not on bedside table. Catheter care Clean every shift or PRN. Same as perineal care Suprapubic caths Long term Patients have for years Prevention of UTIs Confusion is a common sign and symptom Practice frequent voiding No baths Drink lots of water Dont use power Wipe front to back Empty bladder fully Condom cath Noninvasive Used in patients who frequently pull out caths Must have 2 cm from the head of the penis to the tube External urinary device Leg bags Used for mobile patients Catheter needs to be sterile Inflate the balloon to keep the catheter in place Complaints of urge to urinate can mean the catheter is dislodged DO NOT pretest the balloon of the catheter Know how much the balloon will hold so you dont overinflate. The document how much is put in 14-16 french for an adult 8-10 french for a child Interventions for clients with indwelling caths Encourage fluid Catheterize only when necessary Good hygiene Prevent contamination Ongoing assessments Ensure tubing is not clogged Bladder irrigation Done if a patient has had a TERP or blood clots or pts at risk for clots or obstructions Requires a 3 way Foley.

Subtract the irrigation fluid from the output to determine actual urine output. Do not retape traction, it stays until physician orders Clots can give an increased sensation to urinate Urinary diversions When we divert the flow of the urine, the urine does not come out through the urethra Incontinent Pts have to wear a device Assess the stoma Continent Patients have to straight cath themselves every 4-6 hours

Fecal Elimination
Normal defecation is facilitated by thigh flexion and sitting position. The more patients resist the urge to have a BM the urge may just go away. Can lead to impactions or further problems. Important to encourage patients to go. Pg. 1180 figure 46-4 100-400 grams of stool per day is considered normal. Ask what the normal pattern of elimination is to the patient is important. Why test for occult blood o GI bleeds o Colitis o Ulcerative colitis Factors that affect defecation o Age Everything slows High incidences of constipation o Diet 25-35 grams of fiber per day. Increased fiber will help constipation o Activity Mobile patients have more bowel movements. o Psychological factors Laxatives-body can become dependent on them o Diagnostic procedures General Anesthesia can slow BM or cause it to stop. Listen to bowel sounds Ileus means no bowel sounds after surgery. o Pain Hemorrhoid surgery Receiving opioid causes constipation o Common problems Constipation Dry hard stool

Bowel is slow to move Symptom not disease Less than 3 bowel movements per week Tears in the anal mucosa Interventions o Increase fluids o Increase mobility o ROM in bed Diarrhea At risk for dehydration Electrolyte imbalance Especially in kids or older adults Associated with C. diff Hypokalemia can result from diarrhea Lactose intolerance and ulcerative colitis can cause this Interventions o Replace the fluids, either IV or PO Impaction Results from unrelieved constipation Digital removal Need a physicians order Not done as a student Incontinence Cannot control passage of feces May insert a rectal tube (Zozzie)? Hemorrhoids o Seen usually in liver disease Flatulence Caused by foods, abdominal surgery and narcotics Bowel diversions o Temp. or perm. o Lleostomy-illeum is brought to the outside (higher up) Higher instance of obstruction because food is not digested watery o colonoscopy Lower Stool more formed o Most important to know if its a lleostomy or a colonoscopy o Alternative approaches How to care for these patients o Pink or red o May bleed a little o Black or dark purple stoma must be reported to the physician immediately o Assess the skin around the stoma

o Can wash with water o Can use skin protectors o Cut the wafer an 1/8 of an inch away from the stoma o Usually changed once a week Factors with ostomy o Self esteem Smell swimming o infection Assessment o Nursing history Understanding patients normal patters Do they have an ostomy o Physical examination Abdomen, anus, rectum Auscultation first then percussion Planning Implementing o Promoting regular defecations o Teach about meds o Decreasing flatulence Avoid gas forming foods, gum, soda, drinking through a straw o Administering enemas o Digital removal o Bowel training programs Medications o Enemas, h2 blockers, antacids, o Cathartics and laxatives and go lightly Short term action Used for bowel prep for a surgery or colonoscopy Bulk forming, emollient or wetting, saline, stimulants or lobs o Antidiarrheal agents Can be OTC Can be opiates o Enemas Cleansing Prevents escape of feces during surgies Carminative and return-flow Used primarily to expel flatus Retention Oil or meds into the rectum in to the colon 50mL -1L typical volume Height The higher the enema is held up the more you will cleanse Usually 12-18 inches

Cleansing, tap water, normal saline, hypertonic solutions, soapsuds, anal retention. Kayexalate-medication to drop a patients potassium levels. Bulk forming Given as a retention enema Left lateral with the right leg flexed position Insert tube 3-4 inches Stop solution is patient complains of pain and tell them to hold on to it. Hypertonic- fleet phosphate, saline Low pressure Draws water in to the colon and makes feces softer Hypotonic (tap water) Distends the colon Stimulates peristalsis Softens defecation Only done one time, never done more than once o Fluid can reabsorb in to the system o Puts patients at risk for fluid overload. Isotonic (physiologic saline) 0.09% saline Safest because they do not cause a lot of fluid shifting Fluid stays in the bowel Distends the colon Soapsuds (pure soap) Irritate mucosa Stimulate peristalsis Not used as much anymore Oil Lubricates the feces Insertion Lube it Curve with the rectum Roll the fleet enema, do not squeeze it.