Elimination(GU)
CH 49,50,&59
Med Surg 1
Week 5
Urinary Assessment


Family History
Health history

Urine dysfunction

Urgency

Cancer

Frequency

Frequent UTIs

Dysuria

Nocturia

Urine description

Pain

Exposures

Medications

Surgeries

Current Health

Back pain

Flank pain
Urological Terms
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•
Anuria:
urine output less than 100 ml/24 hrs
•
Oliguria:
ml/24 hrs
less than 30 - 50 ml per hour or 100 - 400
•
Polyuria:
unusually large amounts of urine output
•
Frequency: voiding more often than Q2H
•
Urgency:
strong sudden urge to void
•
Dysuria:
burning (pain) on urination
•
Nocturia:
frequent need to urinate at night
•
Hesitancy:
difficulty starting a stream of urine (BPH)
•
Residual:
urine left in the bladder after voiding
•
Retention:
the amount of urine left in the bladder
GU Labs / Tests

BUN (10-20 mg/dl)

Xray

Creatinine (0.6 – 1.3
mg/dl)

CT / MRI

GFR (90-120)

Renal biopsy

Urine Specific Gravity
(1.005-1.03)

Cystoscopy

Renal scan

Urinalysis

Ultrasound

Electrolytes
Urinary Tract Infections
(UTIs)

Most common outpatient infection

Causes

Most common pathogen: Escherichia coli (E. coli)
 75% cases; 65% complicated UTIs

Fungal and parasitic
 Immunosuppressed
 Diabetic or kidney problems
 Received multiple courses of antibiotics
 Live in or have traveled to certain developing
countries
6
Classification of UTI

By location - upper or lower

Pyelonephritis – renal
parenchyma and collecting
system

Cystitis – bladder

Urethritis – urethra

Urosepsis – systemic

Life threatening

Emergency treatment
7
Classification of UTI

Complicated or uncomplicated

Uncomplicated
 Occur in otherwise normal urinary tract in the bladder

Complicated
 Occur in people with underlying disease or other
structural, functional problem

Antibiotic resistance

Immunocompromised

Pregnant

Recurrent infection
 At risk for pyelonephritis, urosepsis, renal damage
8
Clinical Manifestations
Lower UTI

Burning

Frequency

Urgency

Cloudy urine

Inability to void

Malaise- tired, feel bad

Mental status changes
 First symptom of
UTI in elders
Pyelonephritis

Classic: fever/chills,
nausea/vomiting,
malaise, flank pain

Other: dysuria, urgency,
frequency

Costovertebral angle
(CVA) tenderness
UTI Medical Management


Inhibit bacterial
growth- broad
spectrum antibiotic
until C&S completed
Medications
Ciprofloxacin
 Sulfamethoxazole
(Bactrim)
 Nitrofurantoin
(Macrobid)
 Pyridium for burning
pain


Increase fluid intake
3-4 liters/day
 Void every 3-4 hours


Prevent complications
Spread to bladder and
on up to kidneys
(pyelonephritis)
 Prevention of CAUTIs

 Foley care –
cleanse meatus 2–3
times/day
Urosepsis



A gram-negative bacteremia originating in
the genitourinary tract…can lead to sepsis
and death without aggressive, immediate
treatment
Most common is E-coli
People in nursing homes with foleys
 Mental status change
 Hypotension
 Slight fever- often no elevation at all
Urosepsis
•
Other causes: Grampositive bacteria,
fungi, viruses and
parasites
•
Indwelling catheters
and untreated UTI
•
Immunosuppression
therapy
•
Chemotherapy
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Urethritis/Ureteritis


Inflammation of the urethra/ureter due to
bacterial or viral infection

Trichomonas or monilia, chlamydia, or
gonorrhea

Males—sexually transmitted; dysuria,
urgency, and frequency

Females—UTIs, sexually transmitted

Treatment: antimicrobials, sitz baths

Patient teaching: avoid vaginal sprays,
perineal hygiene, no sex for 7 days, and
contact partners
Ureteritis is inflammation of the ureter

S/S Fever, flank pain

Treatment: antimicrobials, sitz baths

Patient teaching: avoid vaginal sprays,
perineal hygiene, no sex for 7 days, and
contact partners
13
Interstitial Cystitis (IC)/
Painful Bladder Syndrome (PBS)

IC—chronic, painful, inflammatory disease of the
bladder; IC causes PBS

Urgency, frequency, bladder/pelvic pain

Urinary pain not attributed to other causes

Etiology: unknown

Possible factors:
 Neurogenic hypersensitivity
 Mast cell changes in muscle or mucosal layer
 Infection (unusual organism)
 Toxic substance in urine
14
Clinical Manifestations
and Diagnostic Studies

Primary clinical manifestations: pain and
bothersome LUTS

Severe: void more than 60 times/day-night

Pain: usually suprapubic but may involve perineum

Increased pain with bladder filling, postponed urination,
physical exertion, suprapubic pressure, certain foods,
emotional distress

Decreased pain with voiding (temporary)

Often misdiagnosed as chronic or recurring UTI or
chronic prostatitis; diagnosis of exclusion

Remissions and exacerbations
15
Interprofessio
nal Care

Treatments

Nutrition and drug therapies

Reduce intake of bladder
irritants

Calcium
glycerophosphate—reduces
irritation

Stress management strategies

Tricyclic antidepressants,
analgesics, antihistamines

Physical therapy and bladder
hypodistention

Botox; cyclosporine A

Surgery—with debilitating pain
16
Urinary Calculi
Urinary Tract Calculi

Nephrolithasis—kidney stone disease

In United States 13% of men and 7% women

Middle-aged; risk increases with age

More frequent in:
 Whites than blacks, Hispanics, and Asians
 Those with family history
 Southeast United States; followed by Southwest, and
Midwest
 Summer (hot climate and dehydration)
 Uric acid stones in Jewish men
18
Predisposition of Stone Formation
Immobility
• Dehydration
• Metabolic disturbances- Diabetes
• History of stones
• High mineral content in water
• Frequent UTI’s
•
Types of Stones
•
Calcium
•
Oxalate
•
Struvite
•
Uric acid
•
Cystine
Clinical Manifestations


First symptom—sudden, severe pain (renal colic)

Flank area, back, or lower abdomen

Ureter stretches, dilates, and spasms

May see nausea and vomiting; “kidney stone dance;”
dysuria, fever, chills; moist, cool skin
Common sites of obstruction

Ureteropelvic junction (UPJ)


Dull costovertebral flank pain or renal colic
Ureterovesical junction (UVJ)

Lower abdominal pain; testicular or labial pain
21
Urinary Calculi
Medical
Management
•
Reduce pain (Priority)
•
Increase fluid to 3-4
liters/day

•
Prevent calculi formation

•
Help flush out stone
Strain urine and then
identify stone make-up
Dietary Recommendations
Urinary Calculi
Surgical Management
•
Cysto- basket removal
•
Lithotripsy
 Laser
 Extracorporeal Shock
Wave
 Conscious Sedation used
•
Break up stones- causes
bruising
•
Strain to catch the
pieces of stone
Open surgical procedure
Nursing Post-Procedure Care
•
Increase fluids!!!!
•
Monitor I&O
•
Monitor for S&S of infection
•
Strain urine!!!!!!!!
•
More stones may follow removal
Urinary Incontinence (UI)

Involuntary leakage of urine

More prevalent with older adults (women more than men)
but not a natural consequence of aging

Gender differences
 Men—common with BPH or prostate cancer; overflow
incontinence from urinary retention
 Women—stress and urge incontinence
25
Urinary Incontinence (UI)
cont.

Bladder pressure greater than urethral closure
pressure


Interference with bladder or sphincter control
DRIP

D: delirium, dehydration, depression

R: restricted mobility, rectal impaction

I: infection, inflammation, impaction

P: polyuria, polypharmacy
26
Types of Urinary Incontinence

Stress
Combined =

Urge
Mixed Incontinence

Overflow

Reflex

Incontinence after trauma or surgery

Functional incontinence

May have more than 1 type
27
Urinary Incontinence (UI) cont.
Medical & Nursing Management
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•
Kegal exercises
•
Bladder training- q 2-3 hours
•
Monitor fluid intake
•
Use of incontinence products
•
Coping
•
Treat with dignity
Urinary Retention

Inability to empty bladder with voiding or the accumulation
of urine because of inability to void

May be associated with leakage or post void dribbling—
overflow UI

Acute urinary retention—inability to pass urine; medical
emergency

Chronic urinary retention—incomplete emptying despite
urination

Post void residual (PVR)—normal 50 to 75 mL

More than 100 mL—repeat or further evaluation with UTIs

More than 200 mL—further evaluation
29
Neurogenic Bladder
•
Bladder dysfunctions caused by tumors of CNS or
PNS.There are several types.
•
Several muscles and nerves must work together
for the bladder to hold urine until ready to
empty it.
•
Nerve messages go back and forth between the
brain and the muscles that control bladder
emptying.
•
If these nerves are damaged by illness or injury,
the muscles may not be able to tighten or relax
at the right time.
Neurogenic Bladder
Medical & Nursing
Management
•
Intermittent Self Catheterization- q 6 hr
•
Bladder Training- urinating every 2 hours,
gradually increasing to every 4 hours
•
Methods to stimulate voiding

•
•
Running water, siting position on
bedpan
Medications

oxybutynin (Ditropan) (urinary
antispasmotic)

bethanechol (Urocholine)
(cholinergic, stimulated muscarinic
receptors causing bladder
contraction
Emotional Support
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Indications for
Catheterization

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Indications for indwelling

Relief of urinary retention

Bladder decompression
preop or postop

Facilitate surgery

Facilitate healing

Accurate I & O—critical
care

Stage III or IV pressure
ulcer

Terminal illness—comfort
32
Suprapubic Catheters

Form of urinary diversion; may be temporary or longterm

Insertion is either through abdominal wall or using a
trocar; general or local anesthesia used; may be
sutured. Tape to prevent dislodgement

Care similar to urethral catheter; use skin barrier to
protect skin at insertion site

Ensure patency: prevent kinking, turn patient side to
side, milk the tube, or irrigate (with order) using sterile
technique

Bladder spasms—antispasmodics
33
Benign Prostate Hyperplasia

Enlargement of prostate gland leading to disruption
of urine outflow from bladder through urethra

Almost 50% of men will have signs of BPH by age 50;
70% by ages 60 to 69

Lower urinary tract symptoms (LUTS)

Difficulty starting a urine stream

Decreased/weaker flow of urine

Urinary frequency
34
BPH cont.

Risk factors for BPH

Aging

Obesity—increased waist circumference

Lack of physical activity

High intake of red meat and animal fat

Alcohol use

Erectile dysfunction (ED)

Smoking

Diabetes

Family history—first-degree relative
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35
Clinical Manifestations of BPH
•
Slow development

Prostatic hyperplasia

Prostatic hypertrophy of the smooth muscle

Increased muscle tone at bladder neck & proximal urethra

Constricted urethral lumen
•
Incomplete emptying of the bladder
•
Urine stasis – UTIs - pylonephritis
•
Hydroureter and Hydronephrosis (enlarged due to retained
urine)
Nursing Management of BPH
•
BPH Education

•
Explain effects of enlargement
Encourage Fluids

Concentrated urine is an irritant

Reduce caffeine and ETOH

Monitor I & O
Surgical Management of BPH
•
Transurethral Resection of Prostrate
(TURP)
•
Prostatectomy
•
•
Now robotic- da Vinci procedure
Post-op Complications
•
Bleeding, infection, erectile dysfunction, incontinence
Continuous Bladder Irrigation (CBI)
•
Insertion of a Three-Way Catheter
•
Continuous infusion of 0.9%Solution (isotonic)
•
Presence of Clots: increase the Irrigation rate
•
Total output minus the amount of irrigation
•
•
solution used = urine output
Catheter Patency is critical
•
If urine is very bloody, speed up the
irrigation flow, so that clots do not form


CBI
Nursing Measures for CBI
•
Maintain irrigation
•
Prevent Infection
•
Secure Catheter

- leg strap
•
Accurate I&O
•
Pain management
-Belladonna & Opium
suppository (B&O)
TURP Post-Op Nursing Care
•
Monitor vital signs
•
Manage Continuous Bladder Irrigation
(CBI)
•
Regulate flow based on urine color
•
Document urine color
•
Accurate I&O
•
Pain Management
Bladder Cancer

Most common urinary system cancer

81,900 new cases/year; 17,240
deaths/year

Older adults more than 55 = 90%
cases

Men more than women; whites >
blacks or Hispanics

Transitional cell cancer—most
frequent


Most are papillomatous
growths
Risk factors: cigarette smoking

Other: industrial exposure
to dyes; cervical cancer
treated with radiation or
chemotherapy; prolonged
indwelling catheters,
chronic, recurrent urinary
tract stones, and chronic
UTIs
43
Clinical Manifestations
and Diagnostic Studies

Most common manifestation: microscopic or gross,
painless hematuria


Other: dysuria, frequency, and urgency
Diagnostic studies

Urine specimens for cancer or atypical cells, and bladder
tumor antigens

CT scan, ultrasound, or MRI

Cystoscopy and biopsy—confirm cancer
44
Nursing and Interprofessional Management

Cancer is graded and staged (I to V)
before treatment; most diagnosed
early

Staging determined by depth of
invasion of bladder and surrounding
tissue

Treatments include:

Surgery

Radiation

Chemotherapy

Intravesical therapy
45
Urinary Diversion
Urine flow blocked from
 Bladder cancer,
neurogenic bladder,
congenital anomalies,
strictures, bladder
trauma, and chronic
bladder inflammation
 Types of surgical
procedures for urinary
diversion
46
Incontinent Urinary Diversion

Diversion to skin; must wear appliance

Most common: ileal conduit (ileal loop)

Colon conduit also used

Ureters anastomosed to conduit; bowel brought to
abdominal wall to form stoma

No valve = no voluntary control

Urine drips into external collection device
47
Urinary Stoma
48
Methods of Urinary Diversion
49
Continent Urinary Diversion

Intraabdominal urinary reservoir that can be
catheterized; has internal pouch

Reservoirs constructed from ileum, ileocecal segment, or
ascending colon

Surgically created valve and large, low pressure reservoir
prevent involuntary leakage; no external collection device

Patient self-catheterizes every 4 to 6 hours

For example: Kock, Mainz, Indiana, and Florida
50
Kock Pouch
51
Orthotopic Bladder
Reconstruction

Construction of a new bladder in correct anatomical
position—urine discharged through urethra

Neobladder surgically shaped from various segments of
intestines; distal ileum common; ureters and urethra sutured
to neobladder

Candidates: normal renal and liver function; 1-2 yr life
expectancy; adequate motor skills; no inflammatory bowel
disease or colon cancer; not obese

Examples: hemi-Kock, Studer pouch, and W-shaped
ileoneobladder

Incontinence may occur; may need intermittent
catheterization
52
Nursing Care of Urinary
Diversion


This Photo by Unknown Author is licensed under CC BY
Pre op

Teach patient
how to care for
appliance

Psychosocial
Concerns (also
post op)
Post op

Complications
(infections,
DVTs, bowel
obstruction)

Monitor I & O’s

Monitor Stoma

Skin care