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					Urinary Elimination

by: Jeremiah B. Eco, RN

Elsevier items and derived items © 2005, 2001 by Elsevier Inc.

Anatomy: The Renal System
Kidneys  Ureters
 • Enter at oblique angle • Peristalsis

– Both prevent reflux
 

Bladder
• Capacity 300–500 ml

Urethra
• Excretion; outside of body. • In Males surrounded by prostate

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Functions of the Renal System
    

Elimination of Metabolic Wastes Regulation of RBC Production Regulation of Vitamin D & Calcium Regulation of Blood Pressure Regulation of Electrolyte, Acid-Base & Fluid Balances

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Function of the Urinary System
(…Cont’d)

• The bladder can contain 1,000 to 1,800 mL of
• • •
urine. Average urine output is 1,000-1,500 mL per day The urethra carries urine from the bladder sphincter to the meatus The internal sphincter relaxes with micturition (urinating reflex). The external sphincter is under voluntary control. At least 600 mL of urine must be excreted per day to remove waste products.
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• •

Elimination of Waste Products


Urea Nitrogen

• By-product of the protein metabolism.
• Measured clinically via serum BUN
– Some amounts normally found in blood; Not a reliable indicator of renal function alone.


Creatinine • A by-product of muscle metabolism.
– Normally, almost completely excreted – A more reliable as an indicator of renal function than BUN.

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RBC Production


Erythropoietin is a hormone that prompts bone marrow to produce RBC’s therefore more HgB to carry oxygen to cells. Secreted in response to decreased amount of oxygen delivered to kidneys (i.e. anemia or hypoxia).



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Vitamin D & Calcium Regulation


Vitamin D from food sources must be converted into it’s active form by the kidneys. Active Vitamin D increases absorption of calcium by the renal tubules and the intestines.





Required to maintain normal calcium balances with the body.

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Blood Pressure & Fluid Regulation


RAAS: Maintenance of blood volume & altering peripheral vascular resistance.
• Specialized JGA cells in the kidneys respond to decreased renal blood flow and pressures by releasing renin…activating angio. I → lungs → angio. II:

– Vasoconstriction – Stimulates aldosterone release from the adrenal cortex = Na & H2O retention (distal tubules). Net Result: ↑ BP & ↑ renal blood flow.


Antidiuretic Hormone (ADH): release from the posterior pituitary = H20 retention (collecting ducts).
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Electrolyte Balances


Potassium
• NL: 3.5 – 5.0 mEq /liter



Sodium
• NL: 135-145 mEq / liter



Calcium
• Total NL: 8.5 – 10.5 mg/dL
• Ionized Calcium NL: 4.5- 5.1 mg/dL



Magnesium
• NL: 1.8 – 2.7 mg /dL



Phosphorous
• NL: 2.5 -4.5 mg/dL
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*See Thalen (pp. 748-749; table 30-2 & 3)

Acid-Base Balance
 Kidneys regulate day-to-day acid-base

balances; not as rapid as lungs.
• Hydrogen: potent organic acidic

• Bicarbonate (HCO3-): principle buffer

CO2 + H20 ↔ H2CO3 ↔ H + HCO3
LUNGS Carbonic Acid
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Kidneys

Factors Interfering with Urinary Elimination
(…Cont’d)

• Blockage of the ureters
       

Stones Tumors in the abdominal cavity Trauma to the lower abdomen Disruption of the bladder by tumor or trauma Enlarged prostate Trauma to the urethra Infection of the urinary system Neurologic damage

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Changes Occurring with Aging

• • • • •

Decrease in the number of functioning nephrons Decrease in the filtration rate Decreased bladder tone—nocturia Decreased bladder emptying, increased residual Hypertrophy of prostate—urethral obstruction Incontinence is not a normal part of aging

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Normal Urinary Elimination

• • • • • •

Infants void 5 to 40 times/day Preschool children may void every 2 hours. Adults void 5 to 10 times per day. Males void 300-500 mL. Females void 250 mL. Average urine output should be approximately 30 mL per hour.

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Factors Affecting Normal Urination

• • • • • • • •

Psychosocial factors Growth and Development Alterations in spinal cord integrity Fluid volume intake Fluid loss in perspiration Vomiting Diarrhea ADH secreted by the pituitary

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Characteristics of Normal Urine

• Normal Urine is clear and straw colored • Specific gravity is 1.010 to 1.030


Specific gravity is affected by dehydration or increased fluid volume intake.

• pH is 5.5 to 7.0 • Normal urine smells faintly of ammonia (affected
by dietary intake).


Foul-smelling urine may be indicative of a urinary tract infection.

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Alterations in Urinary Elimination Patterns

• Anuria
 

Less than 100 mL of urine output in 24 hours
Painful or difficult urination; may result from infection or trauma Involuntary release of urine

• Dysuria

• Incontinence

(Cont’d…)

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Alterations in Urinary Elimination Patterns
(…Cont’d)

• Nocturia


Occurs when a person has to get up more than twice in the night to void

• Oliguria


Decreased urine output less than 400 ml in 24 hours
Excessive urination (greater than 1500 mL in 24 hours)

• Polyuria


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Urinary Specimens

• Normal voided specimen
 

Send to the laboratory within 5 to 0 minutes Urine standing more than 15 minutes changes characteristics

• • • • •

Midstream (clean-catch) specimen Specimen from an indwelling catheter Sterile catheterized specimen 24-hour specimen Strained specimen

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Abnormalities Found in Urine

• Glucosuria
    

Glucose in the urine
Protein in the urine Blood in the urine Pus in the urine Ketones in the urine

• Proteinuria • Hematuria • Pyuria

• Ketonuria

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Nursing History
 Data about voiding patterns and habits  Data about any problems that may affect

urination  Physical Assessment  Diagnostic Tests

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Assessment
Patients should be assessed for: • Usual pattern of elimination • Incidences of incontinence, frequent urination • Burning on urination • Sense of urgency • Times of day for elimination • Total daily fluid intake

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Incontinence

• Loss of normal bladder control • Body image disturbance, increased risk for • • •
impaired skin integrity, increased risk of infection May be temporary or permanent May be corrected by surgery May be helped by performing Kegel exercises

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Diagnosis:
 Altered Urinary Elimination  Fluid Volume Deficit

 Fluid Volume Excess
 Impaired Skin Integrity

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Planning:
 Maintain or Restore normal urination pattern  Prevent:

• Infection • Skin breakdown • Fluids and electrolytes imbalances

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Implementation:
 Promoting Fluid Intake:

• Normal Daily Intake: 1.2 – 1.5 L • Eat raw fruits and vegetables • Diluted urine helps prevent calculi formation
 Maintaining Normal Voiding Habits:

• Positioning • Relaxation • Timing
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 Assisting with Toileting:  Maintain Skin Integrity:

• Perineal Care • Apply Pads or Sheets • Dry Bed Linens
 Catheterization

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Documentation of Voiding
Document: • When a patient is voiding normally (voiding qs) • Whether there is a problem voiding (i.e., dysuria) • Whether the patient is continent • The amount of urine output • Any bladder irrigations • Presence of an indwelling catheter (or when it is removed)

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