Transcript for:
Overview of Urinary System and Elimination

hello everyone in this powerpoint we're going to be looking at urinary elimination specifically in your fundamentals book you would be looking at chapter 30. for the nursing syllabus packet that nursing packet that we give you when we give you the syllabus it's going to be under section this section so it's unit 1 provider of patient-centered care look under specifically module k for the urinary system in that nursing packet you're going to see quite a number of objectives i'm not listing them here but by the end of the powerpoint we will have covered them all the components of the urinary urinary system are the kidneys the ureters the bladder and the urethra you have accessory structures like the internal and external sphincter and this works to allow the urine to pass when you have these major components and these accessory structures working together this is how urine is produced collected and excreted from the body urinary elimination is a process where excess fluids and metabolic wastes are released under normal conditions a person will eliminate eliminate about 1500 to 3 000 ml of urine each day now if you get on shift and you're not aware what's going on with the urinary system of your patient just just realize if the urinary system is not working properly it can be detrimental to the patient so when you come on shift as a nurse uh be aware of what's going on with the bowel system the gi system but also the urinary system don't find out what's going on towards the end of the shift because anything that's out of the normal could be life-threatening now the need to urinate becomes apparent when the bladder distends and stretches when it's getting filled to about 150 to 300 ml of urine so the muscles the in the bladder wall are stretching and they have a stretch receptors that are sending signals to the brain and it's telling the brain hey we're getting full and the brain sends back a signal which gives us the urge to want to urinate and expel the urine the kidneys filter out your total volume of blood in about 30 minutes the average adult has about 5 liters of blood so you can see if you don't have proper kidney function it can be life-threatening the nephron if you look over here the nephron is a basic functional unit of the kidney this is a close-up of how it looks each kidney has about a million nephrons as we age the functions of the nephron diminish over time and if you abuse our bodies like we take drugs we're suffering from diseases you can see how we lose more potential of the nephrons working when a person has to have dialysis basically it's a dialysis machine that's acting like a like a kidney and filtering out all the waste products the nephron maintains fluid balance by selectively reabsorbing or excreting water as our body needs it or not same goes for the electrolytes or any other substances like vitamins and minerals and what not now it also helps to maintain the blood volume and blood pressure so let's say you have fluid overload let's say you have quite a large amount of liquids that you're retaining your blood volume is high your blood pressure is high the kidneys can help with that they help to excrete those extra fluids thus bring down the blood volume and the blood pressure to a normal level the opposite of this is true also let's say you're dehydrated you don't have enough fluids in your body your blood volume is low your blood pressure is low your kidneys can retain any fluids to try to bring up the blood pressure and the blood volume let's look at a video that's going to review the anatomy and physiology of the urinary system arteries and veins and the urinary tract the kidneys are paired bean-shaped organs lying outside the peritoneal cavity in the back of the upper abdomen one on each side of the vertebral column the kidneys function as the body's main excretory organs eliminating the body's metabolic waste products by filtering the blood substances that are unneeded or are present in excess are filtered out of the blood and form into urine moving via the ureter into the bladder before being expelled through the urethra the kidneys also selectively reabsorb those substances that are needed to maintain the normal composition of the blood by adjusting blood composition the kidneys are able to maintain blood volume and pressure ensure the proper balance of sodium chloride potassium calcium hydrogen phosphate and ph and eliminate products of metabolism such as urea uric acid and creatinine the medial border of the kidney is indented by a deep fissure called the high lens where the blood vessels nerves and ureters connect to the kidney the kidney is composed of up to 18 lobes each lobe is composed of nephrons nephrons are the functional units of the kidney and each kidney contains more than one million nephrons each nephron consists of a glomerulus and a system of tubules the glomerulus is a unique high-pressure mass of capillaries that filters the blood the glomerulus is encased in a thin double-walled capsule called bowman's capsule the space inside the capsule and surrounding the glomerulus is called bowman space plasma-like fluid is filtered from the capillary blood into bowman's space through the glomerular filtration membrane the glomerular filtration membrane consists of three layers of capillary wall the endothelium the basement membrane and the epithelium this membrane allows some particles from the blood to pass through but not all the fluid that is filtered from the capillary blood into the bowman's space is called filtrate and forms the primary urine the filtrate then diffuses across bowman's space and into the tubule system of the nephron in the tubules some substances are added to the filtrate as part of the urine formation and some substances are reabsorbed out of the filtrate and back into the blood the nephron tubule is divided into four segments the filtrate passes through each of these segments before reaching the ureter a highly coiled segment called the proximal convoluted tubule which drains bowman's capsule and where almost complete absorption of nutritionally important substances takes place a thin looped structure called the loop of henle which reabsorbs water and ions from the urine and plays a role in controlling the concentration of urine a distal coiled portion called the distal convoluted tubule which regulates potassium sodium and ph and where further dilution of the urine takes place and the collecting tubule which joins with several tubules to collect the filtrate and where final sodium regulation takes place each kidney is supplied with blood by a single renal artery that arises on its respective side of the aorta before dividing into five segmental arteries that enter the highest within the kidney each segmental artery branches into several lobular arteries the lobular arteries further subdivide to form interlobular arteries which branch off into afferent arterioles blood flows into the glomeruli through the afferent arterioles blood flows out of the glomerulus through the efferent arteriole the afferent and efferent arterioles regulate glomerular capillary pressure by selectively dilating or constricting the kidneys venous blood now filtered flows from the glomerulus via the efferent arterioles into the peritubular capillary network a low pressure reabsorptive system surrounding all portions of the tubules this arrangement permits rapid movement of solutes and water between the fluid and the tubular lumen and the blood in the capillaries the peritubular capillaries rejoin to form the venous channels by which blood leaves the kidneys and empties into the inferior vena cava urine formation involves the filtration of the blood by the glomerulus to form an ultrafiltrate of urine the tubular reabsorption of electrolytes and nutrients needed to maintain the constancy of the internal environment and the secretion of waste materials filtration occurs as blood flows into the glomerulus from its afferent arterial and plasma moves through the glomerular capillaries into bowman's space from bowman's space the glomerular filtrate moves into the tubular segments of the nephron here through tubular reabsorption electrolytes and nutrients move from the filtrate back into the bloodstream here also through tubular secretion substances move from the peritubular capillaries into the urine filtrate the filtrate concentrates in the collecting tubules then finds its way to the renal pelvis where it is directed to the ureter the bladder and the urethra for elimination the kidneys perform an excretory function by filtering the blood and then selectively reabsorbing those materials that are needed to maintain a stable internal environment the nephron is the functional unit of the kidney and is composed of a glomerulus which filters the blood and a tubular component where necessary substances are reabsorbed into the bloodstream and unneeded materials are secreted into the tubular filtrate for elimination and urine so let's review what we just saw on the video you have blood coming in through this capillary system and it's entering the bowman's capsule as the capillary system is twisted and there's there's a stretch of capillary vessels in there that all becomes the glomerulus i have a hard time saying glomerulus so the blood's going in it's not filtered once it's filtered it's coming out let's talk about what do we call it when it's going in that's afferent and when it's coming out that's efferent the blood itself should not be leaking into the tubule system you should not see any blood in the urine it's the plasma part of the blood the watery part of the blood that's being filtered out and taking any waste products excess water excess electrolytes with it so the membrane amount around the glomerulus is semi-permeable and it's allowing these waste products these extra products to leave as this liquid portion is forming urine it's collecting in these ducts the first part of the duct is called the proximal convoluted tubule these tubules also have some reabsorption and excretion going on depending how the body needs to keep itself in balance the filtrate the urine is going down the tubules down these ducts and you see how it loops around and becomes longer at this part this is called the loop of henle and this stretch of the nephron this is where lasix works remember we talked about lasix which is also furosemide this is a diuretic it helps the body to excrete extra fluids extra water the other thing about lasix you have to remember is that we also lose potassium so when the water is leaving some potassium is leading when you have a patient taking lasix make sure you keep track of what's happening to the potassium levels and make sure they're maintained in a normal level the end of the duct the end of the tubules is called the distal convoluted tubule there too we can have any remnants of reabsorption or secretion that needs to take place to keep everything in balance now you might say well where does this reabsorption this expression go around these tubules you have a network of capitals so whatever needs to be picked up and taken to the system is picked up whatever needs to be left off in exchange can happen to around these tubules through the blood system and the tubules the main filtration is happening here at the glomerulus where the most of the waste products are being filtered but any kind of balance that you need through these tubules that you need to fine tune any water electrolytes there too you could have reabsorption and secretion now the end of the duct the end of the tubules are collected in a collecting tube these this collecting tube merges together to form and drain into the ureter and of course the ureter leads to the bladder where all the urine collects let's review for a bit how the central nervous system plays the part in urination so you have the central nervous system branching out to the peripheral nervous system then it stretches further to the sensory and to the motor you can look at this also the motor divides further to the somatic the autonomic nervous system the autonomic nervous system branches further to the enteric and enteric is the one that's lining the gi system in the enteric you have both sympathetic and parasympathetic so the autonomic nervous system branches off into the parasympathetic and to the sympathetic and you can see how the parasympathetic plays a part with the detractor muscle let's start here at what you consciously can't control if you look at the pelvic floor muscles the muscles around the perineum and the external sphincter you can control that when you're ready to go you feel like your bladder is full you can consciously open up and relax these muscles and allow yourself to go now the detruster which is the muscles around the the wall of the bladder they're smooth muscles they're controlled by the para para sympathetic nervous system and also the internal sphincter is controlled there too this is not under conscious control it's under unconscious control so when the bladder is getting full the stretch receptors receptors and the trusser muscle is sending a signal to the brain that the bladder is getting full and the brain will send a signal down to to have the the bladder wall the detractor wall contract and squeeze out the urine and at the same time the sphincter muscle is also relaxing so this is contracting so it's squeezing but the internal sphincter muscle is relaxing and it's opening so this is happening from the parasympathetic nervous system and when you're ready you allow the external sphincter and the perineal muscles to relax and allow the urine to pass so for a child that is younger than 18 to 24 months they're not able to control the external sphincter or any of the perineal muscles physiologically they can't do that when a toddler or a child is between the ages of 18 to 24 they're consciously able to start controlling the external sphincter and the perineal muscles also and this gives them more bladder control now another way you can see if they're ready to be toilet trained is you ask them you know are you ready to go they tell you that they are and they can hold it until they're seated at the commode so before the age of 18 to 24 months physiologically the child cannot control these muscles but after the ages of 18 to 24 months they can and of course maturity has a part to do if they're ready to be toilet trained or not so how do we assess our urine sample we coco it also but in this case the second c does not stand for consistency it stands for clarity how clear it is when you put it up against light so we're looking at the color odor clarity and the amount we also coca the urine on table 30-1 and chapter 30 look at the volume the color and the clarity and the odor for normal characteristics versus abnormal characteristics and what does it mean for the volume normally we have between 500 to 3000 mls per day with the average being 1200 abnormal is less than 400 milliliters per day what could be the cause of that low fluid intake excess fluid loss or kidney dysfunction also on the abnormal side for volume if you have three thousand milliliters per day or greater that could be abnormal from having high fluid intake direct medication and endocrine diseases like with pituitary gland for the color it should be light yellow normally if it's dark amber that can indicate dehydration if it's brown that can indicate liver or gallbladder disease reddish brown would indicate blood if it's orange green or blue it could be water soluble dyes or even from medications for that clarity normally when you put urine up against the light you see it's transparent and clear if it's cloudy that could indicate infection or stasis stasis is when urine is sitting around and bacteria start to grow and you can have stasis in the bladder when a person is retaining their urine that's a good environment for bacteria to grow and the urine will look cloudy what is the odor even urine from a healthy person has a faintly aromatic scent we expect that but when urine smells foul that could be infection when it's strong it could be from dehydration when it's pungent it can be from certain foods also another sign of infection is if the urine smells fishy if it also smells like ammonia patterns of urinary elimination can be affected by physiological factors emotional factors and social factors what are some examples of those with physiological factors it could do it could be due to paralysis you might not be able to control the muscles down there because you're paralyzed it can be from infection disease and not just able to control the sphincters due to maturity or even some sort of psychological mental disease for emotional we know that stress and anxiety can also affect our elimination patterns patterns usually when we're under stress we're under under anxiety we're in that fight or flight mode and again just like the blood gets shunted away from the gi tract it also gets shunted away from the urinary tract for social factors when a person is embarrassed that could affect their urinary elimination pattern and also if they're weak or immobile and require the help of another person to go they might not be able to go the restroom or make it on time other factors that affect urinary elimination consider the degree of neuromuscular development like we were talking before when you have a child that's younger than 18 to 24 months they're not able to control control the external sphincter and the perineal muscles and it could also affect an elderly person from disease or weakness or whatnot they can also lose muscle control and strength control and have incontinence the integrity of the spinal cord has a lot to do with how we're going to control our urinary pattern and also the volume of fluids we take if you drink a lot of fluids what has to go in comes out also be dehydrated don't expect much urine to be produced on the amount and type of foods consumed think about potato chips potato chips are very salty and they make you thirsty and when you drink all that water you get puffy the water tends to follow salt now on circadian rhythms it has to do with awake and sleep cycles and where our metabolism is speeding up and slowing down during the night time our urinary system will concentrate the urine so they will so that we won't produce that much urine and fill up our bladder a full bladder will wake you up in the middle of the night when you wake up in the morning and the more you start to move around your metabolism is speeding up and then you start producing more more urine so our urine cycle or your elimination patterns follow also the circadian rhythms our habits have to do with our opportunities to go some people go quite often some people ignore the urge to go also anxiety has a lot to do with our ability to go or not you know when we're under a high amount of stress and anxiety we're in we're in that fight or flight mode the blood gets shunted away from the urinary system and we won't go but let's say you have a low amount of anxiety some nervousness that low amount and anxiety can give you the urge to go more measures to promote urination can include providing privacy draw the curtains give the patient privacy and close the door to the restroom door if it's safe to do so have them sit in the normal sit in sitting position when you're in that normal sitting position you have more control more muscle control to expel more urine if they have to be in bed put them down in a sitting position as much as possible make sure the patient is maintaining adequate fluid intake eight to ten glasses per day is recommended if it's not contraindicated and the patient is not on fluid restrictions they can drink these eight to ten glasses of fluids per day preferably water some patients need help and having the running water run from the tap that sound helps them want to go so try to promote measures to help with the urinary elimination honor food and a fluid intake affecting urinary elimination when you have a proper functioning kidney what goes in must come out and usually that's equal amount unless you configure incessable fluid loss now this is normal this is the amount of fluid we lose through breathing you lose some fluid there through tears into sweat even through the feces you can't measure this fluid loss and it could be as low as 40 it could be as high as 800 milliliters depending on what you're doing let's say you're outside and you're in you're sweating you're losing quite a large amount of fluids but more or less what goes in comes out with a small amount bearing because of insensible fluid loss and sensible fluid loss is normal when you have dehydration the and you don't have enough fluids the kidneys are going to absorb any fluid that's in the body system they're not going to be producing too much urine urine is going to look more amber more concentrated and it should be in a smaller amount because the body is trying to retain those fluids when you have a fluid overload too much water in the body system the kidneys are going to excrete the urine in large amounts and it's going to be dilute urine alcohol acts like a diuretic by inhibiting antiderivative hormone the antiderivative hormone is produced by the pituitary gland and it does what it says it's an antidiuretic hormone so that it doesn't allow water to be excreted and allows water to be retained and that can help with their blood pressure but alcohol offsets that alcohol acts like a diuretic and it causes a person to urinate more foods and beverages high in sodium like tomato juice you know that v8 tomato juice is very salty a bag of chips it's very salty we know that water tends to follow uh salt and that causes us to retain water the purpose of collecting urine specimens is to identify any microscopic or chemical constituents of a client's urine when you have voided specimens you're going to take a sample of fresh urine in a clean container it's best to get the first void of the day so as a patient has been sleeping laying around in bed all night long in the morning you catch that first void it gives the physician an idea if there's an infection going on or not now for a clean catch specimen we want the voided sample to be sterile in order to achieve that we have to catch it midstream there's a technique whether it's for male or female if the patient can do this fine if not we have to do it for the patient when we're in lab we'll go over this in more detail but just to get an idea of what a clean cat specimen is when you catch it midstream you're trying to catch a sterile sample so what you do is you have you can have the patient either sit down or laying down you can wash them with soap and water and the kit usually comes with chlorhexidine wipes so you wipe the outer layer throw it away you wipe the other outer labia throw it away remember you go from front to back especially for female because we have more contamination on the back part since the back part is closer to the rectum so you clean the outer portion throw it away the other outer portion throw it away and then you clean the center and you throw it away you ask the patient to start urinating because that first part of the urine could have microbes in it and then and that could be from the outside of the urethra we just want to make sure we're not adding bacteria that are not actually in the urine sample so you have a patient urinate first try to stop in the middle of urinating and put the cup in place and have them in the middle of urinating again catch that medstream sample that's supposed to be more indicative if there's a bacterial infection or not now be careful with this if you do this in a sloppy fashion and you're introducing microbes what's going to happen is the patient is going to get antibiotics that they didn't need so be very careful when you're collecting a midstream sample because we want it to be sterile when you have a toilet paper feces or menstrual uh blood in a sample that could affect the results if you have a woman that's menstruating and you have to send a urine sample to the lab make sure you you note it somewhere on the paperwork so they're aware that this blood is coming from the menstrual cycle it's not coming from some sort of disease process going on in the urinary system don't include feces or toilet paper that's going to affect the results send the sample to the lab right away and if your laboratory is not closed keep it in the refrigerator now follow your facility policy some facilities say that you can only keep the urine in the fridge for up to two hours and if it's in there more than two hours you could you have to throw it away you don't want it sitting at room temperature at room temperature it's going to grow microbes you want to send it straight to the lab but if it's not going to go to the lab keep it in the refrigerator but just follow your facility policy make sure the lab runner comes and picks up that sample and send it to the lab right away so you can be tested now don't contaminate the specimen cups because your contamination could introduce bacteria and it's going to make make it seem like the patient has an infection they're going to get antibiotics that they don't need now label these specimen cups at the bedside so you'll have less confusion as to whose sample this belongs to here we have a way to collect a urine specimen sample that's sterile from a catheter sometimes patients have to have an endoling catheter because they're unconscious so they're incontinent so what's happening with the androline catheter we also call them a foley catheter the catheter is in the bladder it's being held in place by a balloon and the the urine is being drained through the tubing and it's being collected in the urinary bag you don't want to get a sample from the urinary bag because it's contaminated so how do you collect a sterile sample from this setup first you take the tubing that's close to the patient and you clamp it you can clamp it with a rubber band try not to clamp it for more than 30 minutes you don't want too much urine to be collecting and backing up once you see the urine collecting in the tube clean the port see the port is right here you see it over here clean it with alcohol make sure you're wearing gloves make sure you keep keep this under aseptic technique that means you're not introducing any bacteria to this setup once you clean the port you use the needle system to collect the urine sample place it in a specimen cup make sure that you don't contaminate anything in the process of collecting the sample seal it label it and send it to the lab another specimen sample that you might be called to collect is a 24-hour urine specimen sample so the urine is going to be collected all urine that the patient is producing and a 24-hour period is going to be collected in a jug looking like this this kind of test allows a physician to see what the kidney function is throughout the 24 hour period these other methods of getting a specimen sample kind of give a snapshot at the moment what's happening with the 24 hour specimen sample let's say a physician suspects that a patient is having urinary failure kidney failure they can get a 24 hour idea of what's going on with the kidney function so the urine is collected and placed in a jug like this this jug can be in a water bath water ice bath i should say it's the ice that's keeping it cold and preserving the urine and keeping it from breaking down some of these jugs have a preservative and that preservative keeps the urine from breaking down and you don't have to keep it on ice for that situation so how do we do this 24 hour specimen test post signs so that you know the patient know the family knows and the health care team knows that a 24 hour urine specimen collection is taking place now have a patient void first that first void is not going to be collected you're going to discard it because that's telling what's happening with the kidney function before the 24 hour period so let's say you picked a random time like 8 o'clock you have the patient void first and discard that first urine so from now on eight o'clock to the next eight o'clock period in that 24-hour period you're gonna see what the kidneys are doing and that's gonna be your start time from the first urine that's voided and thrown away in the 24 hour period collect all urine keep it in the jug if any urine is spilled you have to start all over again at the end at the at the final 24 hour mark have a patient take a last void collect that last boy and put it in the jug now keep the container on ice to make sure you preserve it or you can have it in a preservative send label this container and send it to the lab the doctor is going to test to see how the kidney function is doing at the glomerular level here are some definitions to know about abnormal characteristics of urine hematuria means that there's blood in the urine hyuria means that there's pus in the urine and protein or urea means that there's plasma proteins in the urine urine we are allowed to have some amount of proteins in the urine but when it passes a certain point we're calling it protein noria because an excess amount has been in there some more definitions to know albin albumin noria this is urine that contains albumin and albumin is a plasma protein if you recall from 1227 albumin is a plasma protein it's in your blood and it helps produce oncotic pressure so we're supposed to find it in the blood not in the urine sample if you find albumin in the urine sample it could be happening from damage at the glomerular membrane and some albumin could be leaking out glycosyria is when you have glucose in the urine this especially what could happen with a diabetic patient that has their blood glucose out of control once you have so much blood glucose so much glucose in the blood it's spilling over into the urine ketonuria is when you have ketones in the urine ketones are the byproducts of the breakdown of fat this could be somebody that's malnourished or maybe they're on a specific diet they're avoiding all proteins and carbs and the body can use fats to to produce some sort of energy but the byproducts of breaking down fats are ketones and too many ketones in in the body system could could be detrimental we're not supposed to find it in the urine and this test shows ketonuria there was some result of that in the urine here we have some lab considerations that are being tested from a urine sample focus on knowing the creatinine and the via wind but here we're going to discuss about about all of them and show you what the normal range is for each so the color of the urine should be pale yellow it could be straw color to amber the odor can be aromatic the urine as it sits can have an ammonia-like smell so that's why we want to ship it to the lab right away the turbidity is a clarity that means it should be clear and free of infection free of pus free of blood the specific gravity are the particles the components that's in there floating around the dissolved particles the normal range is between 1.005 to 1.030 now one thing i have to talk about lab values they do have trailing zeros because the doctors want to know specifically up to that decimal place exactly what the number is as that so the only place that trailing zeros are allowed are on that values the ph would be between five to eight the normal is about six now the creatinine and the build bun is blood urea nitrogen so these are the byproducts of metabolism in the normal range for creatinine it's zero to 200 milligrams in a 24 hour period if you get a number higher than that you can suspect that the function of the kidneys of the the urinary system is not working correctly and the bun should be 10 to 20 milligrams and 100 ml milli and again this is allowable this is normal if you start to see the building climb to 24 30 60 you know that something is going on that's not in the normal range it could be indicating poor kidney function the gfr it's testing the glomerular filtration rate usually is between 9 to 120 remember i was telling you that a 24-hour urine specimen sample is real good for that test it's really specific for that there should be no ketones in the urine sample and no nitrates nitrates are the breakdown of bacteria same thing with leukocyte if you have the white blood cells going after the bacteria and you see byproducts you know there's an infection going on so we shouldn't see either of those there shouldn't be any bilirubin and urabili bilirubin indicates liver function and how the red blood cells are recycled we do allow a small amount in the normal range you shouldn't see any blood in new red blood cells and some amount of protein is allowed in the blood zero to 20 milligrams per deciliter but beyond that once you start seeing more protein content in the urine specimen it's it's a red flag that something could be going on something's not normal and again there is no bacteria in the urine sample for it to be normal so yes get an idea about all of these but basically focus on the creatinine and the bun these two are good indicators about what's going on with the urinary system if it's functioning properly or if it's not functioning properly here are some more definitions anorea is the absence of urine or a volume of 100 milliliters or less in a 24 hour period so the kidneys are not producing sufficient urine you see this basically when a patient has renal failure and they're on dialysis urinary retention is when the client produces enough urine but they're not releasing it from the bladder for some reason or another we have to investigate why this is happening enuresis that's when you have continued incontinence past the age of toilet training sometimes you have a child that's in the hospital maybe they're the age of 10 and they were fine they were toilet trained they were doing fine but they started exhibiting injuries or bed waiting because maybe they're afraid of being in the hospital maybe they were diagnosed with cancer and and they're living in fear so with injuries especially for a child you don't want to scold them you want to try and find out what's going on and get behind the the reason they feel anxious and why this is happening oligoria is when urine output is less than 400 milliliters in a 24 hour period this can indicate inadequate elimination of urine sometimes it's a sign that the bladder is being only partially emptied for residual residual urine this is when you have more than 50 mls of urine that remains in the bladder after the patient goes to the restroom and voids this is not good because even that amount of urine can support microbial growth and this can lead to infections with urinary stasis it's a lack of movement the urine from the bladder so the the urine sits there it can also create environment for bacteria to grow but it can also cause backup so the urine can back up back up back up from the kidneys and any kind of calcium molecules that are sitting around can precipitate and they can lead to kidney stones or urinary calculi polyuria is when you have a greater than normal urinary volume this may accompany minor dietary variations such as increasing your fluid intake even drinking coffee and tea can increase your urinary output because they're diuretics it can also be caused from taking medications to increase urine production now normally your eyes and o's are about equal and if you can't rule out any dietary changes or any medications that are causing an increase of urine production then you have to figure out if it's some sort of disorder causing polyuria there are two disorders that can cause polyuria we have diabetes mellitus and diabetes insipidus they're not quite the same thing with diabetes mellitus it's an endocrine disorder at the pancreatic level so not enough insulin is being made or the insulin that's being made is not reaching the the cell receptor sites so the person urinates quite a bit because they're trying to flush out that accumulation of glucose in the blood with diabetes insipidus the person feels thirsty they drink a whole lot of water and what's going in comes out what's happening here it's also an endocrine disease it's an abnormality at the pituitary gland the pituitary gland secretes antiderivative hormone and this antiderivative hormone that's secreted helps to maintain our blood pressure the pituitary gland is not working and functioning properly so the person becomes excessively thirsty drinks a whole lot of water and they urinate copious amounts of urine now let's look at nocturia which is nighttime urination for the elderly as a person ages they start to lose the ability to concentrate the urine when you and i go to sleep and our bodies are shutting down and you know slowing down for the night time our urinary system is slowing down and concentrating the urine so that we won't produce so much urine imagine if your body continues to produce the normal amount of urine it does when it's awake your bladder would be full and that full bladder would wake you up as you age you lose the ability to concentrate the urine so a lot of times what's happening with the elderly is they wake up with a full bladder and they go to the restroom you have to be careful there because at nighttime they're trying to call us using the call bell we're not coming to aid them if they're weak or unstable this is where falls happen and injuries can happen now another form of night nighttime urination can be caused from medical problem such as enlarged prostate as the man ages a lot of times they'll have a prostate that's enlarged because the prostate is enlarged and it's around the urethra it's causing urinary retention so not enough urine is is being expelled throughout the day and at nighttime the the patient has an excess amount of urine and they have the the desire to urinate at nighttime and that wakes them up also so there are medicines out there to help with a large prostate one of them is avo dart be careful with apple dart it's used to treat in a large prostate when you touch this medication and let's say you're pregnant especially when it's being crushed or the capsules are being open your body can absorb that powder now normally it's not a problem but if you have a baby especially a male fetus it can cause abnormalities there so make sure that you glove up when you're working with this medication dysteria is a difficult or uncomfortable feeding feeling when voiding is a common symptom after trauma to the urethra or a bladder infection frequency is the need to urinate often urgency is a strong feeling that urine must be eliminated quickly now incontinence that's the inability to control either the urinary or bowel elimination it has to do more with sphincter control whether whether you have some weakness some some loss of strength down in the perineal area or from sphincter control it's going to be more the reason for incontinence now incontinence is not normal because this is achieved after the person had earlier continents now be careful to use the word incontinence as a blanket term for all of our patients sometimes patients have accidents it's not that they're incontinent they're having accidents let's say you had a patient that had a left fracture to the left leg and they were weak they were unstable they had a full bladder all they need is somebody to help them to the restroom it's not that they're incontinent it's just that they can't get to the restroom in time and it's more a problem from the personnel standpoint we don't have enough people helping them or the the staff is ignoring the call for help so be careful and using the word incontinence it's not always that the patient is incontinent it could be more of an accident because the patient did not get help on time now what are the effects of the aging as far as the inner urinary system we know that nocturia can occur more often in the elderly because the kidneys are losing their ability to concentrate their urine and the patient will wake up with a full bladder and want to go as we age the bladder capacity decreases we can't hold as much urine as we could and we have weak pelvic floor muscles all of this can lead to urgency frequency and incontinence as the elderly patient loses the ability to contract the bladder we have urinary retention and stasis occurring and that can lead to utis utis or urinary tract infections one way to help the patient with that is to have them double void so they void wait a few minutes and void again and hopefully that helps with emptying the bladder you can also encourage the patients to drink cranberry juice cranberry juice is thought to not allow bacterial organisms to adhere to the urinary tract and therefore prevent utis or urinary tract infections it's not it's not solid evidence but there is some evidence showing that it could possibly work now another way to avoid urinary tract infections is make sure that they're not sitting in a breeze that's full of urine that could allow for bacteria to grow and they could work its way up also when you clean the patient especially a female try to clean from front to back now here are some other reasons why the patient the elderly patient may not be able to reach the toilet on time or they might lose voluntary control of the sphincters when you have neuromuscular diseases or problems such as lou gehrig's disease or parkinson's that can prevent them from reaching the commode on time when you have degenerative joint diseases like rheumatoid arthritis that's another cause too or they have alterations in thought processes like when they have with alzheimer's they might not even realize that have they have the need to go and also just general weakness now also consider medications that we use for the patients some medications cause them to go to the restroom to want to go to the restroom some of them could be like high blood pressure medications what happens here is that the high blush blood pressure meds basil dilate and pour more fluid into the vascular system some other medications could be antidepressants that can impair the bladder contractions and worsen overflow incontinence symptoms water pills like diuretics pull excess water and salt into the bladder and even sleeping pills clients don't respond and waking up to a full bladder during the night so in order to care for these patients make sure that you provide more frequent voiding especially every two hours when you know that the patient is taking these medications or a diuretic administration now you could restrict fluids in order to control urination but what can happen there is that the patient may still be incontinent and it's gonna they're gonna expel they're gonna avoid concentrated urine and they're gonna lose that normal perception avoiding when they have a full bladder so when you have an elderly patient they perceive the urge to go to the restroom and it's a dire circumstance they need to go as soon as possible do not ignore the call bill get the help they need here we have two types of devices we use to help a patient have a urinary elimination at the bedside we have the commode and we have the urinal we have a urinal for the male and a urinal for the female so for the commode basically it's a chair with a seat the seat has an opening where you can place a receptacle like a bucket to receive the contents you place it at the bedside so the patient doesn't have too far to go for the urinal it's cylindrical and it's used to capture the urine for the male if they don't need help they can use this at the bed in a sitting down position they can lay down to their side or even in a supine position you know whether they're 30 degrees or 40 degrees between the legs they can use this receptacle pretty easy there are times that we have to provide help for the female it's a little bit more difficult you see how the female has to kind of try and make a seal around the urinary opening so none of the contents will leak out but regardless we have the two types of urinal here we have a situation where a male patient might need help with a urinal we pull the curtain to provide privacy we dawn on gloves we ask the patient to spread their legs so we can put the urinal we hold on to the urinal by the handle if the client needs help placing the urinal we can direct the urinal at an angle between the client's legs so that the bottom of it rests on the bed and the opening is higher so the urine will not spill out we can lift the penis of the patient and put it into the receptacle for them to urinate now for the female it's basically the same but when we're applying the the urinal we have to try to make a seal around the opening and prevent leakage it's always a good idea to have a chucks a waterproof pad underneath the patient to prevent any spills or accidents now after the nurse uses the the urinal we prop it promptly empty it clean it out and we measure any eyes and o so this is an output we're going to record it as far as coca remember for urine it's the color odor clarity and amount it's a good idea this is a good practice to rinse the urinals rinse out the urinal make sure you empty out all the contents wash your hands and also provide an opportunity for the patient to watch wash their hands they've been at the bedside using the restroom they also need an opportunity to wash their hands a bedpan can be used on the bed if the patient has to urinate a bedpan is a seedline container used for elimination you can use it also for bowel movements this is a conventional bed pan and this is a fracture pen the fracture pan is a modified version of the conventional pen so when do we use a fracture pen when a patient has had let's say hip surgery or some kind of muscle musculoskeletal surgery and they cannot elevate their hips to place them on top of the bedpan the fracture pan is made so the seating part is less high see this is the part where the patient sits on the conventional pan this is the part where the patient sits on the fracture pan and you see it's more flat it's less high so the patient doesn't have to lift up their hips as high to sit on it if they absolutely can't lift up their hips you can roll them to their side to try to place the pen that way also here are some more considerations to think about in preventing utis have the patients drink plenty of liquids to flush out any possibility of lingering bacteria now recall that cranberry juice is used to try to prevent the the bacteria from attaching to the urinary tract studies are not definitive because they're finding out that in some studies a weaker form of cranberry juice was used versus another but that's still a good possibility that it could help the bacteria or prevent i should say the bacteria from sticking to the urinary tract lining and dwelling foley catheters or any kind of and rolling catheters should be used as a last resort a lot of times we're finding out that catheters are inserted into the patient for the convenience of staff it keeps the patient clean and dry and and prevents accidents but we should be more attentive to the patient to their needs and try to use in drilling catheters as a last resort they are known to definitively cause urinary tract infections in the hospital and joint commission is urging us to stop using indwelling urinary catheters when a patient has an uti especially for the elderly the first sign of a uti could be confusion if you come into a patient's room especially elderly patient you see them confused and when they were urinating it smelled kind of fishy kind of ammonia-like you could sense that there's an infection that can be a clue to you if they're suffering from a uti now we have lower utis and upper utis when you have a lower uti it's in the bladder it's in the urethra it's in the lower part you're going to have pain near the groin near the abdomen near the lower back the patient is going to have a sensation of frequency urgency and even blood when the uti spreads higher it goes up to the kidneys the patient might have flank pain fever nausea vomiting and this can be deadly remember your kidneys filter out the whole content of blood volume so as your blood is being filtered out and it passes through the kidneys and if there's an infection there especially e coli e coli is the most common culprit your blood can pick up the e coli and you can come down with sepsis with sepsis you have like the chemicals secreted from the the bacteria causing blood poisoning it can cause organ failure an organ shut down and even death if they don't catch it in time if they don't get antibiotics to the patient on time make sure you know the difference between the female urinary tract and the male urinary tract if you look at the urethra it's shorter in the female and it's longer in the male when there's bacteria at the end of the urethra for the melt it's easier for the bacteria to be flushed out where you see it's a shorter distance for the bacteria to travel from the urethra opening to the bladder another reason females are more prone to infections is because the urethral opening is close to the the rectum the and even if you clean the rectum very well it's a good environment for bacteria to grow so we encourage the females to wipe from front to back try to keep the area clean and down here if if you're going to be sexually active especially for females make sure you drink glasses of water afterwards to flush out the bacteria try to avoid using spermicides and diaphragm that can be very irritating and predispose you for a uti also with women that have gone through menopause they're making less estrogen when you make less estrogen you don't have as much muscle tone and if you don't have as much muscle tone that means that you can't contract the bladder more urine can stick around as in the form of stasis and cause more bacterial growth also discourage the use of event dwelling catheters like i said before joint commission is discouraging the use of urinary indwelling catheters they're definitely known to cause utis for those patients that are diabetic they're also prone to utis because they have an excess of glucose spilling into the urine and that glucose provides a good environment for the bacteria to grow for the older adults like we've talked in the previous slides we know that they have less ability to contract the their bladder therefore some urine can stick around and provide a good environment for bacteria to grow one of the ways that we can prevent utis and keep track of urinary retention in urinary stasis is by the use of a bladder scan it's non-invasive you don't need a doctor's order to use a bladder scan so if patients are retaining urine a scan should be used to check how much urine is accumulating now first have the patient void preferably have them go to the commode in the sitting position and void so they can completely empty out their bladder have them laid down in a supine position and of course you drape the patient you're going to apply a gel which conducts the ultrasound waves from the conduit from the producer and you get to see the image on the monitor before you start applying the wand check the suprapubic area so it's the area above the pubic area you're checking for any distension from the bladder when you scan the bladder make sure that you're in the proper mode whether it's for a male or a female now also make sure you scan at the center of the bladder if you scan towards the end you're not going to get an accurate measurement so this is a good way for us to see if there's any urinary in retention happening if there's any stasis happening after the patient voids here's a closer look at what a result will look like on a bladder scan if you notice you know here's an image of the bladder it's being used and being taken with ultrasound if you look at this image it's telling you what the quantity is in that bladder when you get a result like this you have to let the physician know and they have to decide if they're gonna have you do a catheterization to remove the urine that's being retained the pvr is a post void residual you have the patient first go to the restroom and void and then afterwards you take a residual volume to see how much urine is left after voiding if the pvr is less than 50 that's considered normal and indicates that the bladder is emptying but if the pvr is 150 milliliters or greater that could indicate retention even pvrs of 100 milliliters or more have been associated with utis so what you do is you let the doctor know so they can decide if they're going to have you insert an indwelling catheter so that's a catheter that stays in there for a long time or a straight catheter which is in and out to empty the bladder there are six types of urinary incontinence in the next slide we'll look at these now and remember it's important to manage incontinence for the older adult plan toilet breaks every 60 to 90 minutes for everyone else that has trouble with incontinence plan about every 90 to 120 minutes and when they're awake take them to the commode every two hours offer them the opportunity to go to the restroom and void assist clients with urgent incontinence assist them to walk slowly ask them to concentrate on holding their urine when they're hearing the toilet so for the first type of incontinence which is stress incontinence this is a loss of a small amount of urine due to abdominal pressure as when you have dribbling when the person sneezes or coughing what's the cause of that when you have weak perineal muscles weak sphincter muscles as when a woman has been pregnant and those muscles become weak so what is a nursing approach to helping with this type of incontinence encourage the patients to do pelvic floor muscle strengthening and reduce their weight if they're overweight so with urge incontinence the patient has a need to avoid and is perceived frequently with short-lived ability to sustain control of the flow voiding commences when there is a delay in accessing the toilet usually you see this with bladder spasms when there's a bladder irritant how does a nurse help try to have the patient restrict their fluid intake to about 2000 milliliters a day emit any bladder irritants such as caffeine or alcohol and administer diuretics in the morning now for reflex incontinence this is spontaneous loss of urine when the bladder is stretched with urine but without prior perception of a need to avoid the person automatically releases urine and cannot control it what happens here to cause this you have damage to the motor and sensory tracks in the lower spinal cord secondary to to trauma tumor or other neurological conditions how can the nurse help you can have cutaneous cutaneous triggering that's when you when you draw like a small triangle around the suprapubic area to kind of influence the the patient to to urinate we do that with babies also you can use straight intermittent catheterization so it's a catheter that goes in a night in and out to help the patient urinate for functional incontinence the patient loses control over urination because they're not able to make it to the toilet on time voiding can occur while attempting to reach the toilet what's usually the cause of this when they're weak their import their impaired mobility doesn't allow them to reach the commode on time they can have physical restraints that don't allow them to get there and they're not able to communicate how can the nurse help modify their clothing add waistbands that have elastic so the patient can pull it down quickly quicker have a bedside commodore urinal so they don't have to go so far to reach the toilet and plant trips to the toilet so they can void here we have total incontinence here you have a loss of urine without any identify pot any identifiable pattern or warning so what's the difference between this and this over here this is happening when the bladder is full it's due to spinal cord damage here it could be due from an altered conscious secondary to a head injury loss of sphincter tone secondary to a prostatectomy or an anatomic leak through urethral vaginal fistula so the person passes urine without any ability or effort or control how do you help this patient you have to provide undergarments like briefs that absorb and allow the patient to be dry as possible you can have an external catheter or an indolent catheter because they're going to be wet pretty much all of the time now on overflow incontinence this is when you have your urine leakage because the bladder is not completely emptied the bladder is distended with retained urine the person voids small amounts frequently or urine leaks around the catheter if they have a catheter in what's causing is is overstretched bladder or weakened muscle tone secondary to obstruction of the urethra by debris within a catheter or in a large prostate or as distended bowel or even a post-operative bladder spasm how does a nurse help keep the patient hydrated and drinking fluids make sure that the bowels are not caught causing a problem and they have adequate bowel elimination make sure that the catheter is patent and flowing in none of the debris are causing a backup also do encourage the cradle maneuver on the cradle maneuver basically the patient is sitting forward putting pressure on their abdomen with both of their hands and this pressure allows them to go and force the urine out here we have the creative maneuver and the cutaneous triggering it's either massaging over the bladder and that usually can trigger the the reflex to void or another way to do it is to tap over it so how do you provide continence training first of all you have to do this with a patient that's cognitive aware and they're able to do this and they're also willing to participate so keep a log of the elimination patterns that the patient has set up some short-term goals with a patient don't restrict fluids keep it on the normal side plan a trial schedule for voiding that correlates to when the patient is usually incontinent and when they have bladder distension if there's no pattern that's identifiable have the patient void every two hours during the day and every four hours at night make sure everyone knows so they're willing to and able to help participate with this have the patient participate in this now assist the patient to the commodore toilet or position them on the bed pattern urinal just right before the scheduled time to go some patients need help with running water so they have a sensation that helps them go again here's a creative maneuver that could help and here's a cutaneous maneuver that could help also for a patient that's paralyzed you can ask them right before you roll void do you feel a chill muscular spasm any restlessness any spontaneous penile erection sometimes that's a clue to their body that is that it's gonna go so have them identify and be aware of that you can also try the cutaneous triggering with a patient that's paralyzed also don't allow patients to sit in their urine besides it causing skin breakdown they're sitting in the bacteria and the bacteria can work its way up and cause utis we need to change the the briefs we need to change any incontinence accidents that they've had make sure that they're not sitting on it more than an hour the urine is pretty caustic it can cause skin breakdown pretty quick now when we're using briefs for any kind of continents uh devices and chucks or whatnot we want to make sure that's not for the convenience of the staff don't just have the staff apply this and ignore the patient they have to be monitored and kept clean and dry in the next few slides we're going to be talking about kind of catheters and wig devices in a few slides now the in-dwelling catheter should be that of a last resort you need to order to um and to administer the adrenaline catheter that's true a lot of times we need them for surgeries or whatnot but when the patient has um administered they're not to have them indefinitely now joint commission a lot of hospital policies have us document what's the reason for having them longer than two to three days it's not for staff convenient remember that involving catheters cause utis and utis can lead to sepsis so make sure we're not using them all the time it's the last resort when a catheter a straight catheter that is goes in and out we use those and now catheters in the hospital we must use sterile technique there are so many germs in the hospital that are resistant to all types of antibiotics so we must make sure that we're not introducing any microorganisms into the patient's urinary system so we must use sterile technique when the patient goes home if they have to use an in and out catheter they're at home they can use a clean technique so as long as they have clean gloves they use a catheter they can wash it with soap and water and rinse it let it dry and they can keep reusing the catheter this way as long as they're using clean technique at home that's okay the germs at home are different now for the toileting schedule the patients should be going after meals and at least every two hours daily to make it easier on the patients we should have waistbands that are elastic so they can pull up and down the undergarments and the pants now for the adults especially the older adults incontinence is not such an easy issue it can cause loss of independence lowered self-esteem restricting their activities the patients can have depression over bladder issues so it's our job to identify what's causing the incontinence is it constipation utis or side effects from medications so don't reprimand anyone not not not even the older adults on their incontinence issue they're already struggling emotionally with what they're going through and that's not having good therapeutic communication with a patient to be demeaning and reprimanding the patients for their incontinence to help our patients we can have them look into the national association for kindness there's a lot of helpful information they can look into there they can get referrals to go to incontinent clinics and that this these clinics can help them with their issues of incontinence kind of train them they can train them to learn how to do the kegel exercises if you look at box 30-1 for the kegel exercises basically they're teaching them how to tighten the internal muscles used to prevent urination so let's say they're urinating ask them to interrupt the urination once that's begun they're using those muscles there in the perineal area to stop the urination tell them to keep the muscles contracted for at least 10 seconds so they can contract them for 10 seconds and then relax them for 10 seconds have them repeat the pattern of the contraction and relaxation 10 to 25 times and they perform this exercise three or four times a day for two weeks to a month this is going to help with strengthening those muscles and helping with sphincter control hopefully helping with incontinence now there are medications for women that help with incontinence for those women that that are going through menopause and they don't have enough estrogen remember the loss of estrogen is going to cause decreased muscle tone when you have decreased muscle tone around the detruster around the sphincter you could have more urinary stasis or you can have incontinence so they can be prescribed topical estrogen this helps treat stress incontinence it helps with muscle tone to improve their incontinence issues anti-spasmodics help with the bladder that's spasming this this helps to treat urgent contents tricyclic antidepressants like elevel will help treat mixed incontinence now let's start looking look closer at the different types of catheters the first one are the external catheters they're applied on the outside they're applied to the skin for the female we can use a pure wick device on the soft side that's touching the female that wakes the urine it's kept in place by the gluteal muscles this device is attached to suction and it's slowly suctioning out any urine for the male you have the external quantum catheter the the catheter is applied the condom catheter is applied and your you attach a drainage tube with a urinary back and it can be kept in place this way the catheter itself there are different tapes as long as it doesn't constrain the the penis it can be used but there are adhesives that we also use to keep it in place now a u-back specimen this is for infants that are not able to achieve continence and we have to get a urine specimen this device with an adhesive it's placed around the opening it's kept in place until enough urine is collected to send to the lab now be careful with latex allergies a lot of these devices are made with latex if the patient is allergic to latex there are different types of catheters out there made with silicon and silicon base so that prevents their their chances of getting a latex allergy these catheters are going to start going inside of the patient so you have to use sterile technique let's first look at the straight catheter the straight catheter has one lumen we call them in and out because when they go inside of the patient we just use them to empty out the bladder or to get a sterile specimen sample and we take them out the patients can be taught to use the straight catheter at home at home they can use clean technique in the hospital environment we have to absolutely use sterile technique now for the and dwelling catheter they're going to be left in the patient for a period of time we've talked about the foley catheter this is the catheter that's inside of the patient this part is inside of the patient it's being kept in place with a balloon you use the port to inflate the balloon and the balloon stays inflated to keep it in place and the other loom in the the second tunnel is connected to a tubing that drains into a urinary bag when you're inserting a straight catheter or an induling catheter they're basically the same except for the end dwelling catheter there's an extra step of inflating the balloon the closed drainage system that's when a device is used to collect urine from the catheter and that's basically the the bag the drainage bag they were attached to the the foley draining system now with a bag they're usually calibrated but the the markings aren't as precise when you're emptying out the the bag you should use a urinal something more precise to measure the urine always keep the bag below the bladder if this bag is lifted at the bladder level or higher urine is going to backflow and that's going to cause urinary retention stasis and that's a a good predecessor for a uti so keep the bag below the level of the bladder when the patient is on the wheelchair we can hang the bag on the wheelchair as long as it's below the bladder if the patient is ambulating let's say they have an iv pole you can attach it to the lower part of the iv pole or have the patient carry it now when you're going to have an indwelling catheter it's important that we have care around the opening we use soap and water to keep the area clean and then we also clean the the tubing so we have to have meticulous care when we're using an indwelling catheter to try to keep things clean now these catheters come in different sizes it's 12 french 14 french 16 so on and so on most adults we go from a 14 16 18 it depends on on the adult when when you have an adult you can start at the the 14 if you're meeting resistance uh don't force it it could be that the catheter is too big or there could be some for sort of blockage but if you have um a catheter that's too small you're gonna have leakage around the opening if you were trying to insert a catheter that's too big you're going to cause damage to the urethra and that could be considered negligent so try to make sure it's the doctor that orders them try to make sure that the appropriate size is entering the patient and if you meet with any resistance stop don't force the catheter in here's a closer look at the closed drainage components you have the calibrated bag you have tubing that's long enough to allow the patient to move try to check the tubing quite often and make sure it's not kinked and you have a hanger make sure the level of the bag is below the patient's bladder level envy out the bag of urine every four to eight hours and if not sooner catheter associated urinary tract infections we call them caudates there are also common infections because the patient picks up this affection at the hospital so how do we prevent them we prevent them by not using and drilling catheters for too long if you're going to use them for more than two or three days you have to justify what that reason is for another way to prevent utis from catheters is to make sure you have meticulous cleaning now if you look at skill 30-2 it walks you through the steps in cleaning the catheter so first you have to start cleaning at the perineal area where the urinary meatus is you're going from cleanest to dirtiest you clean at the urinary meatus and then you go out so you wash it and you rinse it and you dry it this has to be done at least once a day and it can be done at every change of briefs whether whether they've had a bowel movement so it's important to have meticulous urinary care and make sure that we're not allowing bacteria that's sitting on the outside to work its way up into the catheter there are times that it's necessary to flush out the catheter maybe it's not draining as well because there could be some blockage due to sediments so when you're irrigated you can use two ways of irrigating either you can open up the system or you can keep the system closed one thing about opening the system is now you have to be very careful because you can introduce microbes into the open system so what you do is you detach the tubing from the urinary drainage you instill a syringe with sterile saline to flush out the blockage and be careful with that because now it's open to air with a closed system it's similar to when you were trying to get a sterile urine specimen sample you clamp the tubing you instill you instill normal saline that sterile into the port and it flushes out hopefully any sediments any blockage that's there let's look at the triple lumen catheter for continuous irrigation it has three lumens so you see there's one two three lumens one goes for the balloon one goes for the drainage bag and the other goes for the solution that's going to be instilled continuously so this is going to flush out any blood clots or any kind of sediments that could be accumulating and it's a it's a continuous uh at a continuous flow and it's prescribed by the doctor it's used over period days when do we need to irrigate the bladder after you've had urethra surgery bladder surgery or a terp that's prostate surgery so that's trans urethral resection of the prostate you want to make sure that there are no blood clots causing blockage or any kind of tissue debris that could possibly cause blockage now when you see the flow going through let's say you see small blood clots or bleeding that that's going through you don't want it to cause any blood clots and back up the drainage tube you can open up the drainage system slightly to allow to flush and after you see it clear you go back to the prescribed rate that the doctor has now one thing to keep in mind at any point when you see the drainage solution going in and let's say you don't see any drainage coming out that's a red flag to you that the bladder could be possibly because of blockage the bladder could be getting full of this drainage fluid and the bladder can basically explode or pop or burst so make sure what's going in is going out at any time if you see that the drainage is slowing down or stopping stop the flow of the instilling solution and investigate further let me point out a different type of catheter tip a coup de tip that's a curved tip you can see that on a straight catheter you can see that on an induling catheter that helps for a patient that might have slight blockage from a prostate but if the urethra is still intact so if the urethra is not intact whether it's through disease injury or whatnot the doctor can instill can administer a superpublic catheter it's also called a malice catheter so what the physician does is surgically they go through the abdominal wall and they enter the bladder this catheter is kept in place with the balloon and the outside is kept in place with sutures and then it's attached to a drainage bag now the thing about this kind of catheter it is good for long-term use it can be used for months and months and so and so forth i've known a patient that has to have this indefinitely and it's good because it's kept away from the perineal area where micro organisms grow the thing about this catheter is every day you have to check the entry site you have to make sure there's no infection and you have to keep it clean and dry also there's like a drainage pad or like a like a gauze that can be kept around to try to keep the area clean also and you have to check it for for any infection so the malacca catheter can be permanent or it can be temporary sometimes the patient just needs to heal from the urethra or whatnot and then this catheter can be removed or sometimes the damage is permanent through disease or cancer or whatnot and sometimes it has to be this catheter has to be instilled or administered and kept for the rest of the lifetime of the patient here we have reasons for catheterization we do it to relieve bladder distension when a patient can't void to get accurate eyes and o's check their fluid balance when we're trying to get a sterile urine urine sample and we can't do it by other methods when we try to empty the bladder before during after surgery when we're trying to measure residual urine after the patient voids and we know the retaining urine when we're trying to instill bladder medication also for monitoring critically ill patients and increasing comfort for the terminally ill when you get an order to discontinue an endoling catheter these are the general steps to follow perform hand hygiene use clean gloves place the chucks under the patient to catch any spills when you're going to empty out the balloon use a syringe pull back and aspirate to remove the fluid pull out the catheter till all of it comes out check the tip if any piece of the tip is missing that should be a concern you need to stop and report this clean the meatus also check how often the patient voids in the next eight to ten eight to ten hours when the kidneys are working properly they're producing 30 ml of urine per hour so let's say in an eight hour period the patient should be avoiding what's eight times thirty two hundred forty so in the eight hour period the patient should have voided about 240 mls of urine if you see that they're not voiding properly you can do a bladder scan to check for for any kind of retention report it to the doctor they may order another catheterization or whatever further steps need to be taken now on measuring eyes and o's for output try to make sure you use a calibrated device this urinal hat this specimen cup this graduated container is more precise than using a urinal if that's all you have is urinal you can use that but it's better to be more precise now if the patient is incontinent let's say they're urinating onto a breathe or onto a pad it's hard to measure that it's hard to coat it we can basically tell the color we can basically tell the order but it's it's hard to tell how clear it is or even the amount so what you do is that the you could say that the patient urinated in the briefs times two it was heavily saturated you would have to use more descriptors in order to describe what's going on if they're urinating in the briefs try to assist the patient to the toilet every two hours remember that the normal output the minimum normal output of a functioning kidney is 30 ml per hour so you have to calculate let's say you're measuring with what came out in four hours four times 30 is 120 so more or less you're trying to get an idea of what a normal functioning kidney is and if it's below 30 ml per hour you leave you need to let the physician know of the lowered output now when you're draining from the urinary back don't let the spouch touch anything this dr this bag is not so clean as far as bacteria has been sitting there and growing in the urinary bag but you don't want to add to the problem you want to make sure that you're not contaminating it further train the patients in the family not to throw away the urine we need to see it and also they're going to go home train them how to measure the urine accurately now some facilities weigh diapers or i should call them briefs just remember that about 5 500 ml of fluid equals about one pound urinary diversions have to be done when you have a life-threatening situation so with a diversion you have one or both ureters implanted elsewhere we're gonna mostly focus on the urostomy for the urostomy you can have one or both ureters surgically implanted through the skin of the abdomen so you make a stoma out of one or both of them urostomy care for this type of appliance is more challenging because the kidneys are always producing urine remember with the bowels through peristalsis and through your meals you may not always be producing output but with the urine with the urostomy you always are and you have to make sure that the skin around the stoma this peristomal skin is not breaking down and you have to keep things clean and dry and sealed if the appliance is leaking you have to apply and apply a new appliance here we have the different types of urinary diversions one we mostly focus on is this but look at each one this is a conventional ileal conduit so the doctor takes the ilium part of the small intestine attaches both ureters to it and creates a stoma from the helium on the outside so you just need one urostomy bag in this situation the ureter goes through the abdomen this this one is functioning this could happen in a situation where you just have one you're coming to the abdomen like let's say a patient has cancer on that side or a gunshot wound or a knife wound you could have either one or both ureters coming out of the abdomen if you have both ureters coming out of the abdomen you would need two urostomy bags in this situation you just need one this is a vesicostomy so both ureters are going into the bladder as usual but it's the bladder that's being that's being made into a stoma that comes out of the abdominal wall so just think about the bladder part of it is coming through the abdominal wall creating a stoma now for nephrostomy everything is intact but here at the kidney level this is where the catheter is inserted you have to be really really careful with that all of them you have to be careful but here you're right there at the kidney with an indiana pouch it's very cut very similar to the continent ileostomy that we talked about with the bowels so the doctor makes a reservoir using the intestine and what's coming out is not so much a stoma as a valve so the the intestine is sutured in such a way so it won't leak and the person won't need a bag it's more like a valve so you'll need a tube like a catheter to go in and drain it out now in this situation um both ureters are fed into the or attached iso i should say into the sigmoid colon and the sigmoid colon acts as a reservoir and as long as you have intact sphincters it should work well that's it for this presentation if you have any questions or concerns let me know we'll look at the next powerpoint