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Urinary EliminationScientific Knowledge BaseUrinary elimination is the last step in the removal and elimination of excess water and by products of body metabolism. Adequate elimination depends on the coordinated function of _________________________, __________________, ___________________, and _________. The kidneys filter waste products of metabolism from the blood. The ­­­­­­­­­­­­______________________________________ from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra.KidneyThe kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver.Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance. The normal range of urine production is ______________________________. Please convert to CC/day.  Erythropoietin, produced by the kidneys, stimulates red blood cell (RBC) production and maturation in bone marrow. The kidneys play a major role in blood pressure control via the renin-angiotensin system, release of aldosterone and prostacyclin. The kidneys also affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form.UretersA ureter is attached to each kidney pelvis and carries urinary wastes to the bladder.BladderThe urinary bladder is a hollow, distensible, muscular organ that holds urine. The bladder has two portions, a fixed base called the trigone and a distensible body called the detrusor. The bladder expands as it fills with urine. How much urine can the bladder hold?UrethraUrine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence. The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area.Act of UrinationBrain structures influence bladder function.Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxationBladder wall stretching signals micturition center.Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.When a person is ready to void, the central nervous system sends a message to the micturition centers, the external sphincter relaxes and the bladder empties.Factors Influencing Urination (See Box 46-1)Growth and development­­­­­­­­­­­_____________________________­­­____________________________Sociocultural factors_____________________________­­­____________________________Psychological factors_____________________________­­­____________________________Personal habits_____________________________­­­____________________________Fluid intake_____________________________­­­____________________________Pathological conditions_____________________________­­­____________________________Surgical procedures_____________________________­­­____________________________Medications_____________________________­­­____________________________Diagnostic Examinations_____________________________­­­____________________________Common Urinary Elimination ProblemsThe most common problems involve _____________________________________________ or ________________________________________. Problems can result from1. I_____________________________­­­____________________________2. I_____________________________­­­____________________________3. O_____________________________­­­____________________________4. I_____________________________­­­____________________________5. I_____________________________­­­____________________________Urinary retention_____________________________­­­____________________________Urinary tract infection_____________________________­­­____________________________CAUTIsUrinary incontinence_____________________________­­­____________________________Common forms of UI are: (See Table 46-1)1. T_____________________________­­­____________________________2. F_____________________________­­­____________________________3. U/O_____________________________­­­____________________________4. S_____________________________­­­____________________________5. U_____________________________­­­____________________________6. R_____________________________­­­____________________________Urinary diversion­­­­­­­­­­­­­­­­­­­______________________________________________________________Two types: _____________________________________________________________A ureterostomy or ileal conduitNephrostomy tubesNursing Knowledge Base:________________________________________________________________Infection control and hygiene______________________________________________________Growth and development_________________________________________________________ (Focus on older adult Box 46-2)Psychosocial considerations________________________________________________________Critical thinking________________________________________________________________________Nursing Process: Assessment (Box 46-5)Through the patient’s eyes_________________________________________________________Self-care ability_______________________________________________________________Cultural considerations____________________________________________________________(Box 46.4 cultural aspects of care)Health literacy_______________________________________________________________Nursing history_______________________________________________________________(Box 46.5 Nursing assessment questions)Pattern of urination _____________________Symptoms of urinary alterations: (table 46-2) ___________________________________Physical assessmentKidneys___________________________________Bladder___________________________________External genitalia and urethral meatus___________________________________perineal skin___________________________________Assessment of urineIntake and output___________________________________Characteristics of urine___________________________________Color___________________________________Clarity___________________________________Odor___________________________________External genitalia and urethral meatusPerineal skinLaboratory and Diagnostic TestingDiagnostic Examination (Table 46.5 Common diagnostic tests of urinary Tract)Nursing responsibilities before testing:1. ___________________________________2. ___________________________________3. ___________________________________4. ___________________________________Responsibilities after testing include:1. ___________________________________2. ___________________________________3. ___________________________________Nursing Diagnosis: Nursing diagnoses common to patients with urinary elimination problems:Functional urinary incontinenceStress urinary incontinenceUrge urinary incontinenceRisk for infectionToileting self-care deficitImpaired skin integrityImpaired urinary eliminationUrinary retentionPlanningGoals and outcomesSet realistic and individualized goals along with relevant outcomesCollaborate with the patientSetting priorities___________________________________________________________Patient’s immediate physical and safety needsPatient expectations and readiness to perform some self-care activitiesTeamwork and collaboration______________________________________________________ImplementationHealth promotion_____________________________________________________Patient education_____________________________________________________Promoting normal micturition_______________________________________________• Maintaining elimination habits• Maintaining adequate fluid intakePromoting complete bladder emptying______________________________________________Preventing infection____________________________________________________Acute careCatheterization____________________________________________________­­­­­______________Skill 46-2, Inserting and Removing a Straight (Intermittent) or Indwelling CatheterTypes of catheters _____________________________________________________________________Catheter sizes_____________________________________________________________________Catheter changes_____________________________________________________________________Catheter drainage systems____________________________________________________________________Routine catheter care_____________________________________________________________________Preventing catheter associated infection (Box 46-10) _____________________________________________________________________Catheter irrigations and instillations_______________________________________________________Removal of indwelling catheters__________________________________________________________Alternatives to catheterization____________________________________________________________Suprapubic catheters External cathetersUrinary diversionsØ Incontinent diversionsChanging a pouchGently cleanse the skin surrounding the stomaMeasure the stoma and cut the opening in the pouchRemove the adhesive backing and apply the pouchPress firmly into place over the stoma.Observe the appearance of the stoma and surrounding skin.Continent diversionsOrthopic neobladderMedicationsAntimuscarinics: treat urgency, frequency, nocturia and urgency UIBethanechol: treat urinary retentionTamsulosin and silodosin: relax smooth muscleFinasteride and dutasteride: shrink the prostateAntibiotics: treat urinary tract infectionsBe familiar with the medications and indications for all medications your patient is taking.Continuing and restorative careLifestyle changesPelvic floor muscle trainingBladder retrainingToileting schedulesIntermittent catheterization• Skin careEvaluationThrough the patient’s eyesAssess the patient’s self-image, social interactions, sexuality, and emotional statusPatient outcomesUse the expected outcomes developed during planning to determine whether interventions were effectiveEvaluate for changes in the patient’s voiding pattern and/or presence of symptomsEvaluate patient/caregiver compliance with the planSafety Guidelines for Nursing SkillsFollow principles of surgical and medical asepsis as indicatedIdentify patients at risk for latex allergiesIdentify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.Bowel EliminationScientific Knowledge Base_______________________________________________________________Mouth_____________________________________________________________________Esophagus_____________________________________________________________________Stomach_____________________________________________________________________Small intestine__________________________________________________________________Large intestine__________________________________________________________________Anus_____________________________________________________________________Defecation_____________________________________________________________________Nursing Knowledge Base: Factors Affecting Bowel EliminationAge_____________________________________________________________________Diet_____________________________________________________________________Fluid intake_____________________________________________________________________Physical activity_____________________________________________________________________Psychological factors___________________________________________________________________Personal habits_____________________________________________________________________Position during defecation_______________________________________________________________Pain_____________________________________________________________________Pregnancy_____________________________________________________________________Surgery and anesthesia_________________________________________________________________Medications_____________________________________________________________________Diagnostic tests_____________________________________________________________________Common Bowel Elimination Problems_____________________________________________________Constipation (Box 47-1) ________________________________________________________________Impaction____________________________________________Diarrhea_____________________________________________________________________Incontinence_____________________________________________________________________Flatulence_____________________________________________________________________Hemorrhoids_____________________________________________________________________Bowel DiversionsTemporary or permanent artificial opening in the abdominal wall. Stoma­­­­­­­­­___________________Surgical opening in the ileum or colon. Ileostomy or colostomyOstomiesSigmoid colostomyTransverse colostomyIleostomyLoop colostomyEnd colostomyOther ApproachesIleoanal pouch anastomosisContinent ileostomyAntegrade continence enema

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