Urinary elimination and altered patterns

urinary elimination

1. Maintaining elimination

2. Learning outcomes Define the term ‘Elimination’ Identify normal pattern of elimination (urinary & bowel) Discuss the factors influencing bowel & urinary elimination Describe the problems associated with bowel & urinary elimination Analyze the causes for each problem Formulate preventive & therapeutic measures for each problem of elimination Appraise management & nursing care for each problem in elimination

3. Introduction Urinary elimination is a basic human function and essential to health It is nurses responsibility to assess patients’ urinary tract functions and provide support for bladder emptying Urinary elimination depends on the effective functioning of the upper urinary tract’s kidneys and ureters and the lower urinary tract’s urinary bladder, urethra, and pelvic floor During a acute illness, a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised long-term indwelling urethral or suprapubic catheters

4. Introduction cont.…

5. Urinary elimination process The kidneys filter waste products of metabolism from the blood. The ureters transport urine 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.

6. Urination Urination, micturition, and voiding all terms describe the process of bladder emptying. Micturition is a complex interaction among the bladder, urinary sphincter, and central nervous system. Several areas in the brain are involved in bladder control: cerebral cortex, thalamus, hypothalamus, and brainstem. There are two micturition centers in the spinal cord one coordinates inhibition of bladder contraction, the other coordinates bladder contractility.

7. Urination cont.….. As the bladder fills and stretches, bladder contractions are inhibited by sympathetic stimulation from the thoracic micturition center When the bladder fills to approximately 400 to 600 mL, most people experience a strong sensation of urgency. When in the appropriate place to void, the central nervous system sends a message to the micturition centers, stopping sympathetic stimulation and starting parasympathetic stimulation from the sacral micturition center. The urinary sphincter relaxes, and the bladder contracts. When the time and place are inappropriate, the brain sends messages to the micturition centers to contract the urinary sphincter and relax the bladder muscle.

8. Growth and development Socio cultural factors Psychological factors Personal habits Fluid intake Pathological conditions Surgical procedures Medications Diagnostic examinations Factors Influencing Urinary Elimination

9. Factors Influencing Urinary Elimination Growth and Development Children cannot voluntarily control voiding until 18 to 24 months. Older adults may experience a decrease in bladder capacity, increased bladder irritability, and an increased frequency of bladder contractions during bladder filling. Older adults are at increased risk for urinary incontinence because of chronic illnesses and factors that interfere with mobility, cognition, and manual dexterity.

10. Factors Influencing Urinary Elimination cont.… Sociocultural Factors Some cultures expect toilet facilities to be private, whereas some cultures accept communal toilet facilities Religious or cultural norms may dictate who is acceptable to help with elimination practices Social expectations (e.g., school breaks, work breaks) can interfere with timely voiding.

11. Factors Influencing Urinary Elimination cont.… Psychological Factors Anxiety and stress sometimes affect a sense of urgency and increase the frequency of voiding. Anxiety can impact bladder emptying because of inadequate relaxation of the pelvic floor muscles and urinary sphincter. Depression can decrease the desire for urinary continence (ability to control bladder)

12. Factors Influencing Urinary Elimination cont.… Personal Habits The need for privacy and adequate time to void can influence the ability to empty the bladder adequately Fluid Intake If fluids, electrolytes, and solutes are balanced, increased fluid intake increases urine production. Alcohol decreases the release of antidiuretic hormones, thus increasing urine production. Fluids containing caffeine and other bladder irritants can prompt unsolicited bladder contractions, resulting in frequency, urgency, and incontinence.

13. Factors Influencing Urinary Elimination cont.… Pathological Conditions Diabetes mellitus, multiple sclerosis, and stroke can alter bladder contractility and the ability to sense bladder filling. may experience either bladder overactivity or deficient bladder emptying Arthritis, Parkinson’s disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet. Spinal cord injury or intervertebral disk disease (above S1) can cause the loss of urine control because of bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter. Prostatic enlargement (e.g., benign prostatic hyperplasia [BPH]) can cause obstruction of the bladder outlet, causing urinary retention.

14. Factors Influencing Urinary Elimination cont.… Surgical Procedures Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. Urinary retention in the postoperative period has two main causes— one is mechanical obstruction of the lower urinary tract; the other is altered neural control of the bladder and detrusor mechanism, most commonly due to analgesic drugs ( Akkoc et al., 2016).

15. Factors Influencing Urinary Elimination cont.… Medications Diuretics increase urinary output by preventing resorption of water and certain electrolytes. Some drugs change the color of urine (e.g., phenazopyridine-orange, riboflavin–intense yellow). Anticholinergics (e.g., atropine) may increase the risk for urinary retention by inhibiting bladder contractility (Burchum and Rosenthal, 2019). Hypnotics and sedatives (e.g., analgesics, antianxiety agents) may reduce the ability to recognize and act on the urge to void

16. Factors Influencing Urinary Elimination cont.… Diagnostic Examinations • Cystoscopy may cause localized trauma of the urethra, resulting in transient (1 to 2 days) dysuria and hematuria. Whenever the sterile urinary tract is catheterized, there is a risk for infection.

17. Altered Urine Production Most individuals void about 5 to 6 times a day Average daily urine output by age

18. Altered Urine Production cont.… Polyuria Production of abnormally large amounts of urine by the kidneys, often several liters more than the client’s usual daily output. Polyuria can follow excessive fluid intake, a condition known as polydipsia, Associated with diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis. Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss

19. Altered Urine Production cont.… Oliguria and Anuria Oliguria and anuria are used to describe decreased urinary output. Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Although oliguria may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure. Therefore, promptly it should report to the primary care provider. Restoring renal blood flow and urinary output promptly can prevent renal failure and its complications. Anuria refers to a lack of urine production

20. Common Urinary Elimination Problems Frequency voiding at frequent intervals, that is, more than 4 to 6 times per day. An increased intake of fluid causes some increase in the frequency of voiding. UTI, stress, and pregnancy can cause frequent voiding of small quantities (50 to 100 mL) of urine. Total fluid intake and output may be normal. Nocturia Voiding 2 or more times at night. It is usually expressed in terms of the number of times the individual gets out of bed to void

21. Common Urinary Elimination Problems cont.…. Urgency Sudden, strong desire to void. Individual feels a need to void immediately. Psychologic stress and irritation of the trigone and urethra may cause. Common in individuals who have poor external sphincter control and unstable bladder contractions. It is not a normal finding

22. Common Urinary Elimination Problems cont.…. Dysuria voiding that is either painful or difficult. It can accompany a stricture (decrease in diameter) of the urethra urinary infections injury to the bladder and urethra Often patients complains that they have to push to void or that burning accompanies or follows voiding. Often, urinary hesitancy (a delay and difficulty in initiating voiding) is associated with dysuria.

23. Common Urinary Elimination Problems cont.…. Enuresis Involuntary urination in children beyond the age when voluntary bladder control is normally acquired. (usually 4 or 5 years of age) Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. Diurnal (daytime) enuresis may be persistent and pathologic in origin. It affects women and girls more frequently.

24. Common Urinary Elimination Problems cont.…. Urinary Retention Urinary retention is the inability to partially or completely empty the bladder. Acute or rapid-onset urinary retention stretches the bladder, causing feelings of pressure, discomfort/pain, tenderness over the symphysis pubis, restlessness, and sometimes diaphoresis Patients may have no urine output over several hours and in some cases experience frequency, urgency, small-volume voiding, or incontinence of small volumes of urine.

25. Common Urinary Elimination Problems cont.…. Urinary retention cont …. Chronic urinary retention has a slow, gradual onset during which patients may experience a decrease in voiding volumes, straining to void, frequency, urgency, incontinence, and sensations of incomplete emptying. Postvoid residual (PVR) is the amount of urine left in the bladder after voiding and is measured either by ultrasound or straight catheterization. Incontinence caused by urinary retention is called overflow incontinence or incontinence associated with chronic retention of urine. The pressure in the bladder exceeds the ability of the sphincter to prevent the passage of urine, and the patient will dribble urine

26. Urinary Tract Infections (UTIs) Escherichia coli, a bacterium commonly found in the colon, is the most common causative pathogen. The risk for a UTI increases in the presence of an indwelling catheter, any instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence, and poor perineal hygiene practices UTIs are characterized by location (i.e., upper urinary tract [kidney] or lower urinary tract [bladder, urethra]) and have signs and symptoms of infection. Bacteriuria, or bacteria in the urine, does not always mean that there is a UTI. In the absence of symptoms, the presence of bacteria in the urine as found on a urine culture is called asymptomatic bacteriuria

27. Urinary Tract Infections (UTIs) cont.…. Symptomatic infection of the bladder can lead to a serious upper UTI (pyelonephritis) and life-threatening bloodstream infection (bacteremia or urosepsis) and should be treated with antibiotics. Symptoms of a lower UTI (bladder) can include burning or pain with urination (dysuria); irritation of the bladder (cystitis) characterized by urgency, frequency, incontinence, or suprapubic tenderness; and foul smelling cloudy urine. The major risk factors for catheter-associated urinary tract infection (CAUTI) are the presence of an indwelling urinary catheter and the length of its use.

28. Urinary Tract Infections (UTIs) Effective prevention strategies that must be implemented to reduce the risk of CAUTIs include training and education of health care providers and increasing their awareness regarding basic infection control knowledge of optimal hand hygiene practices and Methods for handling indwelling catheter and urine collecting systems appropriately, securing catheters properly, and maintaining unobstructed urine flow and closed sterile drainage system using sterile technique properly

29. Common Urinary Elimination Problems cont.…. Urinary Incontinence Urinary incontinence (UI) is defined as the “complaint of any involuntary loss of urine” a widespread problem among geriatric population 16% to 18% of postmenopausal women develop UI UI can lead to depression, feelings of shame and embarrassment, and isolation, and can prevent individuals from traveling far from home. Older adults have the highest incidence of UI, which puts them at risk for skin breakdown, recurrent UTIs, and falls related to symptoms of urgency. UI is not a normal part of aging and often is treatable.

30. Common Urinary Elimination Problems cont.…. Common types include, stress, urgency, mixed, overflow, and transient and functional . Urgency UI - involuntary leakage associated with urgency also called overactive bladder It is described as an urgent need to void and the inability to stop urine leakage, which can range from a few drops to soaking of undergarments. Normally the bladder contracts on urination. Individuals with an overactive bladder experience contractions while the bladder is filling, leading to an urgency to void, which can lead to UI

31. Common Urinary Elimination Problems cont.…. Stress UI - involuntary loss of urine associated with effort or exertion on sneezing or coughing weak pelvic floor muscles or urethral hypermobility, causing urine leakage with activities such as laughing, coughing, sneezing, or any body movement that puts pressure on the bladder. Factors that make females more likely to experience SUI include shorter urethras, the trauma to the pelvic floor associated with childbirth, and changes related to menopause . For males, SUI may result after a prostatectomy

32. Common Urinary Elimination Problems cont.…. Mixed UI – both stress- and urgency-type symptoms are present The SUI and UUI symptoms do not occur at the same time Usually the individual experiences episodes of isolated SUI and isolated UUI. It is very common among older women

33. Common Urinary Elimination Problems cont.…. Overflow Urinary Incontinence When the bladder overfills and urine leaks out due to pressure on the urinary sphincter. It occurs in men with an enlarged prostate and clients with a neurologic disorder (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury). An impaired neurologic function can interfere with the normal mechanisms of urine elimination, resulting in a neurogenic bladder . The client with a neurogenic bladder does not perceive bladder fullness and is therefore unable to control the urinary sphincters

34. Common Urinary Elimination Problems cont.…. Transient and Functional Urinary Incontinence results from factors outside of the urinary tract (e.g., medications, delirium, infection, constipation). Functional urinary incontinence (FUI) is a subcategory of transient urinary incontinence. FUI is connected with a cognitive or physical impairment ex: unavailable toileting facilities or the inability to reach a toilet due to physical limitations. An individual with cognitive impairment may recognize the need to void but be unable to communicate the need.

35. Common Urinary Elimination Problems cont.…. Urinary Diversions Patients who have had the bladder removed (cystectomy) due to bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent UTI - need surgical procedure that divert urine to the outside of the body through an opening in the abdominal wall (stoma) Urinary diversions are constructed from a section of intestine to create a storage reservoir or conduit for urine Diversions can be temporary or permanent, continent or incontinent

36. Common Urinary Elimination Problems cont.…. Two types of continent urinary diversions Continent urinary reservoir created from a distal part of the ileum and proximal part of the colon ureters are embedded into the reservoir Orthotopic neobladder Anatomically the pouch is in the same position as the bladder was before removal. Allow the patient to void through the urethra using the Valsalva technique

37. Common Urinary Elimination Problems cont.…. Ureterostomy or ileal conduit is a permanent incontinent urinary diversion created by transplanting the ureters into a closed-off part of the intestinal ileum. Open the other end out onto the abdominal wall forming a stoma Patient has no sensation or control over the continuous flow of urine Drainage to be collected in a pouch

38. Common Urinary Elimination Problems cont.…. Nephrostomy tubes Small tubes that are tunneled through the skin into the renal pelvis. These tubes are placed to drain the renal pelvis when the ureter is obstructed. Patients do go home with these tubes and need Teaching about site care & signs of infection