Download Prep for Success Renal Urinary and more Study Guides, Projects, Research Nursing in PDF only on Docsity!
PREP FOR SUCCESS- URINARY FUNCTION
Control of urinary elimination is affected by age-related changes in the kidney, urinary tract, and other body systems. In addition, any age-related change that interferes with the skills involved in socially appropriate urinary elimination can interfere with urinary control. The next two sections review age-related changes that directly or indirectly affect urinary function and control. The primary function of urinary elimination is the excretion of water and chemical wastes, such as metabolic and pharmacologic by-products, that would become toxic if allowed to accumulate. This process depends on all of the following renal blood flow filtering activities w/in the kidneys, functioning of all muscles in the urinary tract, and nervous system control over voluntary and involuntary mechanism of elimination. Control of urinary elimination also depends on cognitive, sensory and ambulatory abilities and on social emotion and environmental factors. Healthy older adults do not experience major functional consequences affecting urinary elimination, but when risk factors are present, which is very common negative functional consequences are likely to happen. Define Pre-renal: as a alteration in the urinary system b/c of something that happen before the kidneys such as a blood flow issue, hemorrhage, dehydration, CHF ● Neuropathic conditions affect the innervation of the bladder such as: Diabetes, MS, Alzheimer’s, spinal cord injury, Parkinson’s Define Post-renal: anything that happens after the kidneys, an obstruction in the flow of urine ex a stone, blood clot, tumor, something to do with the briary prosthetic hypertrophy hyperplasia ● CKD chronic kidney disease, ESRD end stage renal disease, CAUTI catheter associated urinary tract infection Pathway of urinary elimination (A&P review): Note: You can make this chart as you want it to be (below is a simplified version, you can add more arrows if you would like. Ensure competent understanding of topic) Internal and external sphincters regulate urine storage and bladder emptying. The internal sphincter is part of the base of the bladder and is controlled by autonomic nerves. The
external sphincter is part of the pelvic floor musculature and is controlled by the pudendal nerve. When urination takes place, the detrusor and abdominal muscles contract, and the perineal and external sphincter muscles relax. When necessary, the external sphincter contracts to inhibit or interrupt voiding and to compensate for sudden surges in abdominal pressure. Age-related changes involving the loss of smooth muscle in the urethra and the relaxation of the pelvic floor muscles reduce the urethral resistance and diminish the tone of the sphincters. Kidney 🡪 Ureter 🡪 Urinary Bladder 🡪 sphincter 🡪 urethra What does urinary elimination depend on: (1) Renal blood flow (2) Filtering activities w/in the kidneys (3) Functioning of all muscles in the urinary tract (4) Nervous system control over voluntary and involuntary mechanisms of elimination (5) Also depends on cognitive, sensory, and ambulatory abilities and on social, emotional, and environmental factors What is the “widely held perception” about urinary function in older adults? A risk factor that is pertinent to health promotion for older adults is the widely held perception that urinary incontinence is an inevitable and untreatable consequence of aging. Why is this a Risk Factor too? ● Even though increased age is a risk factor for urinary incontinence, it is a major mistake to perceive incontinence as an inevitable and irreversible consequence of aging. ● This commonly held misperception can lead to underreporting and mismanagement of urinary incontinence, with serious functional consequences, including significantly decreased quality of life. ● Studies in the United States and other countries consistently find that older adults with urinary symptoms often delay or avoid seeking help because of embarrassment, lack of knowledge, and the misperception that symptoms are a normal and untreatable consequence of aging. (Watch on the online lecture before filling out)
- Attitudes and knowledge
- Usual patterns of flid intake and voiding
- Risk factors (drugs, diseases, functional limitations)
- Environmental barriers
- Signs and symptoms of urinary dysfunction What are nursing interventions for promoting urinary wellness in older adults?
- Teaching about normal urinary function
- Teaching about preventing and alleviating incontinence and UTI’s
- Managing incontinence Degenerative changes of renal tubules affect the dilution and concentration of urine. This can lead to (p.396): Functionally the renal tubes in older adults are less efficient in the exchange of substances the conservation of water, and the suppression of ADH secretion in the presence of hypo-osmolality. Age-related changes also decrease the ability of the older kidney to conserve sodium in response to salt restriction ● Predispose the older adults hyponatremia, fluid and electrolyte imbalances, particularly in the prescence of any condition that alters renal circulation, H2O or Na balance, plasma vol. or osmolality
A&P Reminder: BLADDER & URINARY TRACT (kidney 🡪 ureters 🡪 bladder 🡪 ___) Mechanisms of the physiologic process (p.396) : After being filtered by the kidneys, liquid wastes pass through the ureters into the bladder for temporary storage. The bladder is a balloon-like structure composed of collagen, smooth muscle (called detrusor), and elastic tissue. Liquid wastes are eliminated from the bladder through a complex physiologic process involving the following mechanisms, which are affected by age-related changes:
- The ability of the bladder to expand for adequate storage and to contract for complete expulsion of liquid wastes
- The maintenance of higher urethral pressure relative to intravesical pressure
- Regulation of the lower urinary tract through autonomic and somatic nerves
- Voluntary control of urination (micturition) through the cerebral centers Are the above mechanisms impacted by age related changes? Yes Bladder capacity in the Young adult: 450ml Older adult: 350ml ● Urination can be controlled as long as the volume does not rise above (young 450ml and old 350ml). ● If the vol. rises above then the detrusor muscle contracts involuntarily, the intravesical pressure will exceed the urethral pressure, and leakage of urine is likely to occur. Factors that influence INTRAVESICAL AND URETHRAL PRESSURE BALANCE:
- Abdominal pressure
- Thickness of the urethral mucosa
- Tone of the pelvic, detrusor, urethral and bladder neck muscles
- Replacement of the smooth muscle tissue the bladder and urethra w/ less elastic connective tissue. What regulates urine storage and bladder emptying? Internal and external sphincters regulate urine storage and bladder emptying.
difficulty maintaining continence. In addition, adequate fluid intake is essential for clearance of pathologic organisms from the classer and prevention of bacteriuria. How does constipation increase chances of urinary incontinence? Constipation and altered mental status are adverse effects of medication that can increase the risk for urinary incontinence. RISK FACTORS- Describe the following (look for main points) : MISPERCEPTIONS______________________________________________________
Consequences: ____________________________________________________
Describe 2 Functional Impairments that you have witnessed which could increase the chance of urinary incontinence in an older adult: Functional and cognitive impairments are a major risk factor for the development of incontinence because they can interfere with the ability to recognize and respond to the urge to void in a timely manner. ● Cognition, balance, mobility, coordination, visual function, and manual dexterity ● Identification of a designated receptacle in a private area ● Accessibility and acceptability of toilet facilities ● Ability to get to and use a suitable receptacle ● Amount of time between the perception of the urge to void and the actual need to empty the bladder Ability to voluntarily control the urge to void o Because older adults have a shorter interval between the perception of the urge to void and the actual need to empty the bladder, any delay in reaching an appropriate receptacle can result in incontinence. Thus, dependency in performing activities of daily living (ADLs) for any reason increases the risk for urinary incontinence. o Conditions such as arthritis or Parkinson disease may slow the ambulation of older adults as well as their ability to manipulate clothing for toileting. o Likewise, dementia and other conditions that impair cognitive abilities can interfere with the timely processing of information that is necessary for maintaining voluntary control over urination. Describe 2 Environmental conditions which could increase the chance of urinary incontinence in an older adult that spoke to you the most: ● Stairways between the bathroom level and the living or sleeping areas
● A distance to the bathroom that is more than 40 ft ● Living arrangements where several or many people share a bathroom ● Small bathrooms and narrow doors and hallways that do not accommodate walkers or wheelchairs ● Chair designs and bed heights that hinder mobility ● Poor color contrast, as between a white toilet seat and light-colored floor or walls ● Public settings with poorly visible or poorly color-contrasted signs designating gender-specific bathroom facilities ● Public settings with dim lighting and out-of-the-way bathroom facilities ● Very bright environments, where glare interferes with the perception of signs for bathrooms ● Mirrored walls, which reflect bright lights and create glare What is the best color for a toilet seat for an older adult? Use contrasting colors for the toilet seat and surroundings, (according to google Red) Provide an example on how urinary incontinence can be prevented or minimalized during early/middle stages of dementia : An increased risk for urinary incontinence is associated with many pathologic conditions including all the following: stroke, arthritis, dementia, delirium, depression, diabetes mellitus, metabolic syndrome, Parkinson disease, and chronic obstructive pulmonary disease (COPD). Dementia is strongly associated with urinary incontinence; however, the relationship between these two conditions is complex, and episodes of incontinence can often be prevented or minimized, particularly during early and middle stages. For example, older adults with dementia and urge urinary incontinence may lack the perceptual abilities that are necessary for finding and using appropriate facilities in a timely manner, but they may be able to maintain continence when given appropriate cues and reminder What can be done with water soluble medication orders? (p.401) Age-related change are most likely to affect water soluble medications that are highly dependent on GFR(glomerular filtration rate) (gigoxin, cimetidine, and aminoglycoside antibiotics) or renal tubular function (penicillin and procainamide). Unless medication dosages are adjusted to account for age-related changes in GFR and renal tubular function, excretion
AGE-RELATED changes in Voiding Patterns
- The bladder of the older adult has a smaller capacity, empties incompletely, and contracts during filling. So the older adults experience shorter intervals between voiding and they have less time between the perception of the urge to void and the actual need to empty the bladder. “When you gotta go, you gotta go.”
- Bladder retains residual urine after voiding causing symptomatic or asymptomatic bacteriuria and predisposing older adults to UTIs.
- Diurnal production of urine causes a shift in voiding pattern to more urinary output at night than during the day. o Nocturia (i.e., the need to void one or more times during the night) increases with age and is the most commonly cited reason for nocturnal awakenings, with more than half of older adults voiding at least once during the night. o Nocturia is a common symptom of many urinary tract disorders, and it also occurs with systemic conditions such as endocrine disorders, heart failure, renal insufficiency, and certain medications, such as diuretics. FUNCTIONAL CONSEQUENCES of Nocturia : o disturbed sleep o increased risk for falls and hip fractures o decreased quality of life What is the main cause of female genitourinary conditions? Pelvic floor disorders, refers to a group of medical conditions in which a pelvic organ prolapses into the vagina due to weakness or injury involving muscle and connective tissue of the pelvic floor and related structures Define Cystocele Urinary Bladder Define Cystourethrocele Bladder and urethra Define Urethrocele Bladder and neck Define Enterocele part of the small bowel and peritoneum Define Rectocele/Rectal prolapse rectum FUNCTIONAL CONSEQUENCES of the “cele’s” that affect urinary function:
- lead to urinary frequency
- and incontinence b/c these conditions interfere w/ the complete emptying of the bladder, resulting in residual urine and an increased risk for bacteriuria Describe how Benign Prostatic Hyperplasia influences urinary function: a common cause of voiding problems in older men because the enlarged prostate compresses the urethra, which leads to obstruction of the vesical neck. FUNCTIONAL CONSEQUENCES of BPH that affect urinary function: 1.. As the condition progresses, the urinary musculature becomes thinner and less elastic
- and urinary retention occurs, increasing the risk for bacteriuria and infection
- Men with prostatic hyperplasia may experience decreased urine flow,
- incomplete bladder emptying, and urinary urgency and frequency
- What happens when the ureters & kidneys overflow from this condition? Eventually, the ureters and kidneys are affected, and hydroureter, hydronephrosis, diminished GFR, and uremia may develop. Risk Factors ( Pathologies & Vocab from online lecture ):
- Pre-renal (before kidneys) conditions i.e. blood flow issue, hemorrhage, dehydration, CHF)
- Neuropathic -affects the innervation of the bladder ( i.e. Diabetes, MS, Alzheimers, spinal cord injury, Parkinsons)
- Post-renal (after kidneys) obstruction of the flow of urine due to stone, blood clot, tumor, BPH
- CKD – chronic kidney disease
- ESRD – end-stage renal disease, see this with a dialysis patient
- CAUTIs – catheter-associated urinary tract infection, a problem with Medicare. Medicate will not pay URINARY INCONTIENCE : Describe the Mnemonic for CAUSES (RISKS) D elirium I nfection A trophic- in urethra and vaginal area as women ages and estrogen levels decrease P harmaceuticals E xcessive urine output-happens with hyperglycemic state or CHF on diuretics R estricted mobility
- Urinary retention not controllable by other interventions like meds or a sterile intermittent catheter or straight cath.,
- Urinary incontinence and a stage3/4 pressure ulcer on the trunk of the body (shoulders to buttocks)
- Terminal illness for comfort reasons (when they are about to die and for the management of the family) What condition can indwelling urinary catheters cause? CAUTI’s develop after 2 days of the indwelling catheter having been placed or w/in 1 day of removal ASSESSMENT (back to the book!) Distinguish between a UTI and asymptomatic bacteriuria: Asymptomatic bacteriuria- is the presence of bacteria in the properly collected urine of a patient that NO SIGNS OR SYMPTOMS of a urinary tract infection UTI- an infection of any part of the urinary tract system UTI and asymptomatic bacteriuria, which is characterized by urinalysis results of 10^5 or more colony-forming units but a lack of localized symptoms, such as dysuria (pain during urination). ● Asymptomatic bacteriuria is very common in older adults, particularly in long-term care settings and in those with indwelling catheters. ● An important nursing consideration is that even though the urinalysis shows bacteriuria, treatment for asymptomatic bacteriuria is not warranted and, in fact, may be harmful! What is the most accurate indicator of Glomerular Filtration Rate in the older adult? In an older adult, the serum creatinine may not be an accurate indicator of GFR (glomerular filtration rate), but a 24-hour urine sample collection may have greater value as an indicator of renal functioning Renal HOSPICE Qualifications:
- Palliative performance sale V a. cancers
- End stage renal disease: renal failure w/out dialysis Apply HEALTH PROMOTION that nurses can do for renal/urinary function in the older adult. Self-Care Actions:
● Drinking adequate fluid prior to exercise and avoiding strenuous physical activity in hot or humid conditions ● Teach older adults about measures to protect themselves in very hot or humid environments by using fans and sir conditioners, maintaining, good fluid intake, and avoiding alcoholic, carbonated and caffeinated beverages. ● B/c older adults w/ diminished renal function are at increased risk for adverse effects when taking one or more water-soluble medications, dose adjustments may be necessary Address Risk Factors: ● A risk factor that can be alleviated through health education is the false perception of incontinence as an inevitable and irreversible effect of aging. Nurses have important roles in addressing risks for urinary incontinence as an integral aspect of health promotion. ● For example, interventions for preventing constipation, may improve control over urination. Similarly, health education about the rationale for maintaining adequate fluid intake as a means of preventing incontinence and maintaining good urinary function is a simple but important intervention. Also, explain that because the sensation of thirst diminishes or is absent in older adults, this is not a good indicator of the need for fluids.
PELVIC FLOOR MUSCLE EXERCISES also called pelvic floor muscle training, self-care practice that is effective as a first-line intervention for men and women with stress, urge and mixed incontinence, and in women with pelvic organ prolapse Purpose: To prevent the involuntary loss of urine by strengthening the pelvic floor muscles. Position: Lying, sitting, walking, or standing with the muscles of your thighs, buttocks, and abdomen relaxed. Techniques to Identify the Pubococcygeal Muscle Contract the muscle that stops the flow of urine. Do NOT do this regularly when urinating. ● Tighten your pubococcygeal muscle and hold for a period of at least 3 seconds; gradually increase the contraction time by 1 second per week until you can do a 10-second squeeze. ● Relax this muscle for an equal period; rest and take deep breaths between contractions. • Do 10 sets of a contraction–relaxation cycle (one exercise) three times daily. ● Breathe normally during these exercises, and do NOT tighten other muscles at the same time. Be careful not to contract your legs, buttocks, or abdominal muscles while you are contracting your pubococcygeal muscle. ● For each of the daily sessions, vary your position (e.g., perform the exercise while lying down in the morning, standing in the afternoon, and sitting in the evening). o Additional information: You can ask your primary care practitioner for a referral to a physical therapist or continence advisor who can teach you to do these exercises. Teach a female patient how to do this: o Imagine that you are sitting on a marble and trying to suck it up into your vagina. o Lie down and insert a finger about three quarters of the way up your vagina. Squeeze the vaginal wall so you feel pressure on your finger and a sensation in your vagina. Teach a male patient how to do this: o Stand in front of a mirror and try to make the base of your penis move up and down without moving the rest of your body.
How often does this exercise need to be performed? Frequency: Minimum of 3 sets of 10 contractions/relaxations daily, continued indefinitely. When can results to expected? Results: Most people begin to notice an improvement in urinary control after 3 to 6 weeks, but some will not notice the improvement until several months later Describe CREDE’s Maneuver ( From next lecture! Got it online) : Credes Manuever is a technique used to void urine from the bladder of an individual who cannot pee When would you use this? The Credé maneuver is a simple and effective voiding technique for managing patients with a flaccid bladder, large bladder capacity, low bladder storing pressure, or an incompetent or relaxed external and/or internal urethral sphincter When would you not use this? Long-term use of the Credé maneuver isn’t safe. You shouldn’t use the Credé maneuver as the primary way to empty your bladder if you have a condition that causes urinary retention. You should only use it temporarily until you can empty your bladder through other more efficient methods, such as a Foley catheter. Continence Training: When incontinence cannot be alleviated, it can be managed with the use of various aids and equipment, such as incontinence products and collecting devices. When used in conjunction with environmental modifications to increase the accessibility of toilet facilities, such equipment usually has beneficial effects; however, when aids and equipment are used by caregivers as substitutes for other methods of promoting continence, they are beneficial only to the caregiver and are detrimental to the older adult
intentionality on the part of the dependent person in their failure to control urination, these feelings will likely be intensified. o Nurses play key roles in promoting caregiver wellness by teaching caregivers about the importance of addressing all treatable contributing conditions. o Nurses can base their health teaching on the information already discussed in the Nursing Interventions subsections and use Box 20-11 to teach caregivers of older adults who have urinary incontinence.
