THE ASSESSMENT AND CARE FOR IMPAIRED URINARY ELIMINATION

PN 134

ASSESSMENT

Pain on urination Pattern of urination Strength of urine stream Urgency, frequency, incontinence,

hematuria, nocturia Intake and output Urine color, clarity, and odor

URINARY RETENTION

Urinary retention Etiology/pathophysiology

The inability to void despite an urge to void

Clinical manifestations/assessmentDistended bladderDiscomfort in pelvic regionVoiding frequent, small amounts

URINARY RETENTION

Client may experience discomfort and anxiety.

Frequency of urination and voiding small amounts may occur.

Treatment: urinary analgesics and antispasmotics.

Urinary catheter may be used, or surgery if indicated.

When client able to void, check for residual urine-should be less than 50mL.

URINARY RETENTION

Stasis may lead to infection. Distended bladder may result. Caused by stress, calculus

obstruction, stones, tumor, infection, medications, trauma.

URINARY RETENTION

Medical management/nursing interventionsWarm shower or sitz bathNatural voiding position if possibleUrinary catheterSurgical removal of obstructionAnalgesics

URINARY RETENTION

Urinary Analgesics Pyridium, Pyridate, phenazopyridine: Uses: relief of pain associated with

lower genitourinary tract Adverse Reactions: headache, rash,

pruritis, GI disturbances, discoloration of the urine, sclera and/or skin.

Dosage range: 200 mg TID PO

Urinary Incontinence

Etiology/pathophysiologyInvoluntary loss of urine from the bladder

Total incontinence; dribbling; stress incontinence

SecondaryInfection; loss of sphincter control; sudden change in pressure in the abdomen

Permanent or temporary

URINARY INCONTINENCE

Stress: leakage of urine on straining. Urge: sudden need to urinate. Overflow: full bladder leads to

leakage. Total: no control of voiding. Nocturnal enuresis: night time

incontinence.

Urinary Incontinence

Clinical manifestations/assessmentInvoluntary loss of urine

Leaking with coughing, sneezing, or lifting

Medical management/nursing interventionsTreat underlying causeSurgical repair of bladderTemporary or permanent catheterBladder trainingKegal exercises

Urinary Tract Infections

Etiology/pathophysiology UTIs are caused by pathogens that enter the

urinary tract – with or without presence of symptoms

Bacteriuria (bacteria in the urine): the most common of all nosocomial infections; often associated with urinary catheters

Common in older people r/t bladder obstruction, insufficient bladder emptying, decreased bactericidal secretions of the prostate, increased perineal soiling in women, sexual intercourse.

Urinary Tract Infections

Immobility, sensory impairment, and multiple organ impairment may increase the probability of infection in the older adult

Females more susceptible because shorter urethra and proximity to vaginal and rectal area.

Urinary Tract Infections

Gram-negative microorganisms from the GI tract (e.g. E. Coli, Klebsiella, Proteus, or Pseudomonas) commonly cause UTIs. They ascend through the urinary meatus.

Body usually keeps infections in check by washing them from the body through voiding.

If there is incomplete emptying of the bladder or reflux of urine, the retained urine supports growth of bacteria.

Urinary Tract Infections

Clinical Manifestations Urgency, frequency, burning on urination Microscopic or gross hematuria Cloudy or blood-tinged urine Nocturia Abdominal discomfort, perineal or back

pain Sudden onset incontinence or increased

incontinence Type of infection depends on location:

cystitis, urethritis, nephritis, etc.

Urinary Tract Infection

Treatment Pharmacology: antibiotics Common ones:

Norflaxin (Noroxin) Nitrofurantoin (Furadantin) Sulfisoxazole (Gantrisin) Trimethoprim-Sulfamethoxazole

( Bactrim, Septra)

Urinary Tract Infection

Diagnostic Tests: UA, C&S

CYSTITIS

Inflammation of the urinary bladder. Caused by escherichia coli, candida

albicans, coitus, prostatitis, diabetes mellitus.

Culture, sensitivity testing, antimicrobial medication, urinary tract analgesic.

Increase fluid intake, record I & O.

CYSTITIS

Encourage fluid intake. Should drink between 3-4 liters of non-caffeinated fluid a day.

Intake of meats and whole grains makes the urine more acidic and may discourage growth of bacteria in the urinary bladder.

Drinking cranberry juice

PYELONEPHRITIS

Bacterial infection of renal pelvis, tubules, interstitial tissue of one or both kidneys. Also known as pyelitis or nephropyelitis.

Usually associated with pregnancy, chronic health problems such as DM, polycystic or hypertensive kidney disease, insult to the urinary tract such as catheterization, infection, obstruction, or trauma

PYELONEPHRITIS

Kidney becomes edematous, inflamed; blood vessels congested

Urine may be cloudy and contain pus, mucous, and blood

Small abscesses may form in the kidney

Symptoms of acute condition: chills, fever, flank pain, prostration

PYELONEPHRITIS

Repeated episodes chronic pyelonephritis and atrophy of the kidney with nephrons being destroyed.

Destruction of nephrons Azotemia: retention in the blood stream of excessive amounts of nitrogenous compounds

Treat to prevent from becoming chronic

PYELONEPHRITIS

Diagnostic tests could be: IVP, UA and C&S, CBC, BUN, serum creatinine.

Collect urine specimens before administering antimicrobials

Pharmacology: sulfonamides (Bactrim,Cipro); antipyretics if with fever, analgesics if in pain.

Immunological Disorders of the Kidney Nephrotic syndrome

Etiology/pathophysiologyPhysiologic changes of the glomeruli

interfere with selective permeability Clinical manifestations/assessment

Proteinuria; hypoalbuminemiaGeneralized edemaAnorexiaFatigueOliguria

Nephrotic Sydrome

http://www.youtube.com/watch?v=-ebByDNbTWI

Immunological Disorders of the Kidney

Medical management/nursing interventionsCorticosteroidsDiureticsDiet

Low sodiumHigh protein

Immunological Disorders of the KidneyImmunological Disorders of the KidneyNephritis (acute glomerulonephritis) Etiology/pathophysiology: in taking a

health hx., will usually find that an infectious disease process triggers an immune response.Frequently a beta-hemolytic streptococcus (2-3 weeks prior)

The immune response inflamed glomeruli excretion of RBCs and protein in the urine

Immunological Disorders of the KidneyImmunological Disorders of the Kidney

Clinical manifestations/assessmentEdema of the face – esp. around eyesPallorMalaiseAnorexiaDyspnea with exertionHematuria – “cola” colored frank

bleedingChanges in voiding patternsOliguria; dysuria

Immunological Disorders of the Kidney

Diagnostic Tests: Blood tests will usually show: elevated BUN, serum Creatinine, potassium, ESR, and antistreptolysin-O titer.

Urinalysis will show presence of RBCs, casts, and protein

Treatment includes drug therapy, diet, and rest.

Treat to prevent renal complications, cardiac complications, and complications to cerebral functioning.

Immunological Disorders of the KidneyImmunological Disorders of the Kidney

Medical management/nursing interventionsAntibioticsTreat primary symptomsDiureticsAntihypertensivesDiet

Protein and sodium restrictionsIncrease calories

Immunological Disorders of the Kidney Pharmacology

Prophylactic antimicrobial therapy possible

Drug of choice is Penicillin Diuretic and antihypertensive drugs may

be ordered Corticosteroids, chemotherapeutic

drugs, and/or immunosuppressive drugs to control inflammatory response.

Immunological Disorders of the Kidney

Nursing Interventions Focus is on control of symptoms and prevention

of complications Monitor level of consciousness if BUN is elevated VS , I/O Bedrest and fluid adjustments are guided by

urine output until diuresis is adequate Level of Activity: depends on the degree of

edema, BP, proteinuria, and hematuria – all of which increase with excessive activity

Immunological Disorders of the Kidney Patient Teaching

Nature of illness Effect of diet and fluids on fluid balance and

sodium retentionDiet: prescribed sodium and fluid restrictionInfo on protein restriction/ CHO sources for

energy Medication Pacing daily activities Avoiding trauma and infections S/Sx that require medical attention Importance of medical follow up

Immunological Disorders of the KidneyImmunological Disorders of the Kidney

Nephritis /Chronic Glomerulonephritis) Etiology/pathophysiology

Slow, progressive destruction of glomeruli

Commonly caused by other chronic illnesses

Diabetes mellitusSystemic lupus erythematosus

Immunological Disorders of the KidneyImmunological Disorders of the Kidney

Clinical manifestations/assessment Malaise; morning headaches Dyspnea with exertion Visual and digestive disturbances Generalized edema Weight loss Fatigue Hypertension Anemia Proteinuria

Immunological Disorders of the KidneyImmunological Disorders of the Kidney

Chronic Glomerulonephritis (cont.) Medical management/nursing

interventions Same as acute glomerulonephritis

Bedrest, dietary modification, medication Goal: prevent further renal damage;

prevent cerebral and cardiac complications

Renal dialysis Kidney transplant

Immunological Disorders of the Kidneys

PharmacologyAntimicrobial therapy given

prophylacticallyDiuretics and antihypertensive drugs

ordered

PHARMACOLOGY

Types of diuretics:Thiazides: hydrochlorothiazideLoop diureticsPotassium sparing diureticsOsmotic diureticsCarbonic Anhydrase inhibitor diuretics

PHARMACOLOGY

Diuretics:

-drug that increases the secretion of urine. -kidney disease often causes excess fluid

retention (edema). -many different types of diuretics used for

different purposes.

PHARMACOLOGY

Antihypertensives methydopa (Aldomet) minoxidil ( Loniten) hydralazine HCL ( Apresoline) Monitor BP, pulse, postural

hypotension, and K, Na,Cl, and CO2 and I&O

PHARMACOLOGY

Phosphate binding antacids: aluminum hydroxide gel ( Amphogel)

Potassium exchange: sodium polystrene

Electrolyte Replacement: calcitrol (Rocaltrol)