Kidneys
Two bean-shaped organs 6 cm wide x 12 cm longLocated at level of L1 on either side of the spine-each one contains approximately 1 million nephrons
Nephrons
-Inside each nephron is a glomerulus consisting of a cluster of capillaries surrounded by Bowman's capsule and a system of tubules- they are the working units of the kidneys
Ureters
-Hollow tubes that carry urine from the kidneys to the bladder-Each ureter is 25 to 30 cm long
Bladder
-Hollow muscular organ located in lower pelvis that stores urine-sterile area, and is vulnerable to infection
Urethra
-Carries urine from bladder to meatus; flow controlled by urinary sphincter-Meatus—conducts urine to outside the body
functions of the kidneys in elimination
-Filter blood through the nephrons-Metabolic waste and excess water are extracted-Regulate electrolytes by excreting excess amounts and help with acid-base balance retaining hydrogen ions and bicarbonate-Tubules secrete, excrete, or reabsorb electrolytes, water, and other substances
how much circulating blood supply do the kidneys receive?
20% to 25%
three parts that compose nephron?
proximal tubule, loop of Henle, distal tubule
what does filtrate collected in the distal tubes become?
urine
what urinary structure is involved in the renin production that influences blood pressure?.
kidneys
Efficiency of kidney function promotes the circulation through the
renal arteries and renal veins
how much urine do kidneys manufacture in 24 hours?
1.5 L
Function of Ureters in elimination
transport urine from the kidneys to the bladder
function of bladder in elimination
holds urine until the urge to urinate develops
When does the bladder empty?
when 250-400 mL of urine is present*under voluntary control*
How is urine transported?
through the ureters by gravity and unidirectional peristaltic waves; there are no sphincters between the bladder and the ureters.
if urine output is less than 30 mL?
patient may be experiencing decreased tissue perfusion and/or decreased cardiac output.
how much urine can the bladder contain?
1000-1800 mL
Average urine output per day
1000-1500 mL
function of the urethra in elimination
carries urine from bladder sphincter to the meatus
function of the internal sphincter in elimination
relaxes with micturition (urinating reflex)
function of the external sphincter in elimination
is under voluntary control
how much urine should be excreted per day to remove waste?
600 mL
what can happen if there is a spinal cord or pelvic nerve damage?
voluntary bladder control may become impaired. The bladder will continue to fill but may become distended
what type of muscle is the bladder?
smooth muscle controlled by the parasympathetic nervous system, making this a voluntary and learned activity
Factors Interfering with Urinary Elimination
-Total loss of kidney's ability to manufacture urine-Decreased kidney profusion-Blockage of the ureters-Disruption of the bladder by tumor or trauma-Infection-Neurologic damage to the nerves-Prostate surgery
Changes Occurring with Aging
-Decrease in the number of functioning nephrons-Decrease in filtration rate-Decreased bladder tone—nocturia-Decreased bladder emptying, increased residual-Enlargement of prostate—urethral obstruction-Incontinence is NOT a normal part of aging
Usual urine output for adult
30 to 70 mL per hour
what is the normal urinary elimination for infants?
void 5 to 40 times/day
what is the normal urinary elimination for preschool children?
may void every 2 hours
what is the normal urinary elimination for adults?
void 5 to 10 times per day
what is the normal urinary elimination for males?
void 300 to 500 mL
what is the normal urinary elimination for females?
void 250 mL
average normal urinary output
30 mL/hr
Factors Affecting Normal Urination
-Neurologic and muscle development-Alterations in spinal cord integrity-Fluid volume intake-Fluid loss in perspiration-Vomiting-Diarrhea-ADH secreted by the pituitary
what situations does Antidiuretic hormone (ADH) influence fluid balance?
•responds to changes in the fluid osmolality of the blood; determines how much the tubules reabsorb or discharge.•If fluid intake (by mouth, IV) is decreased (or lost through vomiting or diarrhea), it is released to increase the absorption of water.•If fluid intake is increased, it is suppressed, allowing more urine formation (diuresis).
Normal color of urine
Straw-colored or amber
clarity of urine
transparent or only slightly cloudy
odor of urine
faintly like ammonia
Specific gravity of urine
Normal range is 1.010 to 1.030-is influenced by protein and glucose.-is also influenced by the use of IV contrast used for imaging studies
pH of urine
Slightly acid, ranging from 5.5 to 7.0
anuria
Less than 100 mL of urine output in 24 hours
dysuria
Painful or difficult urination; may be from infection or trauma
incontinence
Involuntary release of urine
nocturia
When a person must get up more than twice in the night to void
oliguria
Decreased urine output less than 400 mL in 24 hours
Polyuria
Excessive urination (>1500 mL in 24 hours)
Common renal function tests
renal concentration, creatinine clearance, serum creatinine, and BUN
cystitis
-Inflammation of the bladder-May be caused by irritation of highly concentrated urine, pathogenic bacteria, injury, or instillation of an irritating substance
Cystitis symptoms
frequency, urgency, dysuria, burning, malaise, foul-smelling urine, slight temperature elevation
What bacteria are often responsible for cystitis?
Pathogenic
urine specimens
Normal voided specimenMidstream (clean-catch) specimenSpecimen from an indwelling catheterSterile catheterized specimen24-hour specimenStrained specimen
Normal voided specimen
-Send to the laboratory within 5 to 10 minutes-Urine standing more than 15 minutes changes characteristics
what are the nurse's role for collecting urine specimens?
•Patient teaching•Barrier precautions•Sterile technique•Timely collection•Prompt transport to lab•Monitoring and reporting results
what should patients be assessed for?
-Usual pattern of elimination-Incidences of incontinence, frequent urination-Burning on urination-Sense of urgency-Times of day for elimination-Total daily fluid intake
Glycosuria
glucose in the urine
Proteinuria
protein in the urine
Hematuria
blood in the urine
Pyuria
pus in the urine
Ketonuria
ketones in the urine
different catheter types
-Robinson-Foley-Suprapubic-Coudé-Alcock-de Pezzer-Malecot-Condom
Performing catheterization
-Sterile equipment and aseptic technique-Procedure for male and female catheterization is similar-Variations in the positioning, draping, and cleansing of the urinary meatus
incontinence of urine
-Loss of normal bladder control-Body image disturbance, Increased risk for impaired skin integrity, Increased risk for infection-May be temporary or permanent-May be corrected by surgery-May be helped by performing Kegel exercises
Electromyography
evaluate the neuromuscular function of urination
urinary diversion care
-Necessary when the bladder is removed or bypassed--Skin care depends on the type of diversion
what are ureters implanted to during urinary diversion care?
-The abdominal wall (urostomy)-The bowel-A pouch constructed from a piece of bowel
what should be documented for elimination?
-When a patient is voiding normally (voiding sufficiently)-Whether there is a problem voiding (i.e., dysuria)-Whether the patient is continent-The amount of urine output-Any bladder irrigations-Presence of an indwelling catheter (or when it is removed)
Structures Involved in Waste Elimination
small intestine, large intestine, Ileocecal valve
function of the small intestine in bowel elimination
Processes chyme into a more liquid state-Adds bile from the liver to help break down fats-Villi on the walls absorb nutrients
function of the large intestine in bowel elimination
-Absorbs water, sodium, chlorides-Waste material stored until expelled
what does the small intestine include?
duodenum, jejunum, ileum
function of the ileocecal valve in the small intestine
Controls flow of chyme into the large intestine
what does the large intestine include?
-Ascending colon-Transverse colon-Descending colon-Sigmoid colon-Rectum-Anus
what are the four layers of the intestines?
-Mucosa-Submucosa-Muscular layer-Serous layer (serosa)
what does peristalsis do in the intestines?
moves chyme and gas through the intestines (causing bowel sounds)
what is the normal transit time in the intestines?
18-72 hours
where are feces stored?
the sigmoid colon until the gastrocolic reflex initiates defecation
defecation
is under voluntary control and uses the Valsalva maneuver
Effects of Aging on the Intestinal Tract
-Atrophy of the villi-Decreased absorption of fats, vitamin B12-Decrease in motility-Bowel habits should not change in the normal healthy individual
what is the color of normal stool?
light to dark brown
what is the normal consistency of normal stool?
soft-formed in children and adults; consists of ¼ solids and ¾ water
what affects the appearance of normal stool?
diet and metabolism
what is the composition of normal stool?
solid materials consist of 70% undigested roughage from carbohydrates, fat, protein, and inorganic matter, and 30% dead bacteria
What happens when flatus is not expelled?
It is usually reabsorbed for further breakdown.
Blood in the stool
most serious abnormalityFresh red blood: bleeding in colonOccult blood: upper GI bleed (black stool called melena
Pale white or light gray stool
absence of bile in the intestine
other abnormalities in stool include
Large amounts of mucus, fat, pus, or parasites
What symptoms may indicate upper GI bleeding?
Some pain and discomfort; the nurse should also look for signs and symptoms of decreased blood volume; i.e., fatigue, shortness of breath, pale conjunctivae, low blood pressure
Hypoactive Bowel and Constipation
-Indicates a decrease in peristalsis-Usually results in constipation-A patient restricted to bed are at risk -Flatus (gas) accumulates in the intestinal tract when peristalsis reduced or absent
Drugs That May Contribute to Constipation
narcotic analgesics-codein, morphine, meperidineGeneral anesthetics-Diuretics-Sedatives-Anticholinergics-Calcium channel blockers
Drugs Used for Constipation
Stool softeners-Colace, Surfak, DialoseBulk-forming laxatives-Fibercon, Metamucil, CitrucelIrritant/stimulant laxatives-Dulcolax, Neolid, Ex-Lax, Correctol, SenokotSaline laxatives-Citrate of magnesia, milk of magnesia, phospho-soda
hyperactive bowel
-Increase in peristalsis-Usually results in diarrhea-May be self-limiting
what are some cause of hyperactive bowel?
Inflammation of GI tract, infectious diseases, diseases such as:-Diverticulitis-Ulcerative colitis-Crohn's diseaseMany antibiotics kill normal bowel bacteria, resulting in diarrhea
what should patients with diarrhea from antibiotics replace lost normal flora with?
-Eating yogurt-Drinking buttermilk-Taking acidophilus (available OTC)
Medications Used to Control Diarrhea
-Camphorated tincture of opium (paregoric)-Diphenoxylate hydrochloride with atropine sulfate (Lomotil)-Loperamide hydrochloride (Imodium)-Difenoxin hydrochloride with atropine sulfate (Motofen)
What is fecal incontinence?
Lack of voluntary control of fecal evacuation; inability to retain feces
What causes fecal incontinence?
-Illness-Cerebrovascular accident-Traumatic injury-Neurogenic dysfunction
what may fecal incontinence cause?
-a loss of dignity-Feelings of being less of a person-Loss of self-respect-Embarrassed-Anxiety or fear of losing control
some factors in the initial assessment of a patients bowel elimination
-Does patient have a bowel problem?-Usual bowel pattern-Any measures used to promote defecation?-Use of enemas or laxatives-Usual eating habits and exercise-Foods that produce diarrhea or constipation-Disorders that contribute to constipation or diarrhea
physical assessment of bowel elimination
Shape of the abdomen with the patient supine-Flat, distendedAuscultate for bowel sounds in all four quadrantsPercuss for presence of excessive air/gas in the abdomenPalpate for masses or tenderness
Rectal Suppositories
-Used to promote bowel movements-Glycerin and bisacodyl suppositories-Promote bowel evacuation
what do rectal suppositories do?
-Stimulate the inner surface of the rectum and increasing the urge to defecate-Form gas that expands the rectum-Melt into a lubricating material to coat the stool for easier passage through the anal sphincter
Enemas
-Fluid introduced into rectum by means of a tube-Stimulate peristalsis or wash out waste products-Often given before a colonoscopy or an x-ray
volumes of typical cleansing enemas
-Infants: 20 to 150 mL-Ages 3 to 5 years: 200 to 300 mL-School-age: 300 to 500 mL-Adults: 500 to 1000 mL
What three factors determine the type of enema given to the patient?
The patient's age and condition, the reason for the enema, and the physician's preference.
what is a retention enema?
Softens stool as oil is absorbed
what is a cleansing enema?
-Stimulates peristalsis through distention and irritation of colon and rectum-Adults is between 500 and 1000 mL; smaller amounts are used for children
What is a distention reduction enema?
enema that relieves discomfort from flatus causing distention
what is a medicated enema?
Solution with drugs to reduce bacteria or remove potassium
what is a disposable enema?
Stimulates peristalsis by acting as irritant(small volume)-Contain about 240 mL of solution-May be given at room temperature, but work best when slightly warmed
Why should a cleansing enema not be given too rapidly?
Causes painful distention of the rectum and colon. This stimulates the urge to defecate immediately, so that the patient cannot retain the fluid.
Fecal Impaction
-Means that the rectum and sigmoid colon become filled with hardened fecal material--Most obvious sign is the absence of (or only a small amount of) bowel movement for more than 3 days in a patient who usually has a bowel movement more frequently-Occurs in patients who are very ill, are on bed rest, or are confused
bowel training for incontinence
-Regular time for evacuation should be established-All efforts must be made to provide patient with environment that is conducive to evacuation-May require digital stimulation to relax the anal sphincter-Suppositories, stool softeners, and bulk laxatives used to assist in establishing a normal, regular bowel pattern
what are some principles for establishing a regular bowel elimination?
-Adequate diet-Sufficient fluids-Adequate exercise-Sufficient rest
What is a bowel ostomy?
-A diversion of intestinal contents from their normal path-Results in formation of an external opening called a stoma-May be an internal tissue pouch with a valve opening-Special procedures aid in effective, controlled elimination through the stoma
What is an ileal conduit?
Diversion of the small bowel contents to a pouch or stoma; effluent is liquid
What is a colostomy?
-Diversion of the colon-Effluent may be liquid or solid depending on the site; may require irrigation
skin care with an ostomy
-stoma and skin washed with mild soap and water and patted dry-Skin barrier paste is applied
Applying an ostomy appliance
Appliance is positioned with the stoma protruding through the opening in the center of the faceplate
Irrigating an ostomy
A solution is instilled into the colon via the stoma
occult blood
or old blood is suspected when the stool changes from a normal brown appearance to a dark color whit a sticky appearance
what temperature should the enema solution be?
105 degrees Fahrenheit
average size catheters used
female: 14 to 16 Fr.male: 18 to 20 Fr.
when to do Kegel exercises?
contract the muscles and hold for 10 seconds and relax for 10 secondscomplete this 3 times per day
what could be the first sign of infection?
subtle changes in mental status
what does white bloods cells in the urine mean?
there is infectious or inflammatory process somewhere in the urinary tract
What is the Crede maneuver?
massage the bladder from top to bottoms by rocking the palm of the hand downward steadily