王克芳 [email protected] 0531-88382201 山东大学护理学院 Elimination.

王克芳[email protected]

0531-88382201

山东大学护理学院

Elimination

2 WKF SON SDU护理学基础

能正确陈述尿液、粪便观察的主要内容。能举例说明影响排尿、排便的因素。能识别常见的排尿异常与排便异常。能正确解释导致排尿异常和排便异常的原因。能针对患者的情况制定改善排尿异常与排便异常的

护理措施。能运用所学知识对患者进行排泄护理健康教育。能规范完成导尿术与灌肠术的操作。

学习目标


Anatomy and Physiology

Assessment of Urination

Nursing Interventions for Urination

Nursing Skills for Urination

Urinary EliminationUrinary EliminationSection 1Section 1

Anatomy and Physiology

Kidneys

Diameter: 1.25 cm Length: 20 to 30 cm

--Hollow, distensible, muscular organ Organ of excretion Reservoir of urine

Urine formation Hormone production

Internal sphincter External sphincter :voluntary

M:18-20cm3个狭窄2个弯曲

M:18-20cm3个狭窄2个弯曲

F ： 4-5cm，短、直、粗

F ： 4-5cm，短、直、粗

Ureters

Bladder

Urethra


Act of Urination

Act of Urinationvolume 400-500ml

bladder stretch sensor micturition center（ S2-S4）

spinal cord

detrusor muscle contract

internal urethral sphincter relaxing

Voding--Emptying bladder

micturition center（ brain stem, cerebral cortex）

external urethral sphincter relaxing

Pelvic nerve

Desire to void

Pelvic nerveparasympathetic impulses


Urinary EliminationUrinary EliminationSection 1Section 1

你经历过或听别人说过所谓的排尿方面的问题吗

案例


Problems

Ignore the urge External sphincter remains contracted

Eventually, bladder capacity is maximum Pressure on sphincter makes voluntary control impossible

Neurogenic bladder Spinal cord injury above sacral region

Loss of voluntary control of urination: incontinence

Sacral region injury Retention

Blockage Retention


Assessment of Urination

Normal Patterns

Altered Urinary Elimination

Factors Affecting Urination


Normal Patterns

Times

Amounts

Color

Clarity

Specific gravity

pH

Odor


Times: 3-5 at daytime 0-1 at night

Amounts: 200-400 ml/time 1000-2000 ml/24hr

Normal Patterns


Color Pale, straw to deep yellow – normal

More concentrated in morning

Dark red Bleeding from kidneys or ureters

Bright red Bleeding from bladder or urethra

Dark amber High levels bilirubin

Liver dysfunction

Normal Patterns


Clarity Transparent when fresh – normal Foamy--Kidney disease Thick and cloudy--Bacteria

Specific gravity 1.015-1.025

Higher Concentrated urine: Dehydration, reduced renal blood flow, increased ADH

Lower Dilute urine: Overhydration, early renal disease, inadequate ADH

Normal Patterns


pH 4.5-7.5 average: 6.0 Indicates acid base balance

Odor Slightly aromatic (fresh) – normal

Ammonia --Stagnant Sweet or fruity

Diabetes Starvation

Normal Patterns


Altered Urinary Elimination

Oliguria （少尿） , Anuria （无尿） , Polyuria （多尿）

Frequency （尿频） , Urgency （尿急） , Dysuria （尿痛）

Urinary Incontinence （尿失禁）

Retention of urine （尿潴留）

Oliguria Anuria Polyuria

<400ml/24 hr

Dehydration

Renal failure

Increased ADH

>2500ml/24 hr

Excess fluid intake

Diabetes

Diuretics

<100ml/24 hr

Severe shock

Acute renal failure

Frequency--Urination at more frequent intervals Increased fluid intake Bladder inflammation Increased pressure on bladder

Urgent micturition --A sudden strong desire to urinate Full bladder Urinary tract inflection Psychological stress

Dysuria--Difficult or painful urination Bladder inflammation Trauma Inflammation of urethra

膀胱刺激征 (Bladder Irritation Syndrome)


Urinary Retention( 尿潴留 )

Definition: Holding urine in the bladder and can’t excrete voluntary 尿液大量存留于膀胱内而不能自行排出

Causes Urethral obstruction Trauma Altered motor and sensory innervation of bladder Medication side effects anxiety


Urinary Incontinence

Definition International Continence Society (ICS) ：

Condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable

客观存在的不自主性尿液排出，并对社会活动和个人卫生造成不良影响。


Categories of Incontinence

压力性尿失禁（ Stress Incontinence ）

充溢性尿失禁（ Overflow Incontinence ）

急迫性尿失禁（ Urge Incontinence ）

功能性尿失禁（ Functional Incontinence ）


Stress Incontinence

Occurs with increase in abdominal pressure coughing, straining, sneezing, lifting heavy objects, etc.

The most common type in women, mid-aged, elderly A result of weakened pelvic muscles A malfunction of the urethral sphincter

Childbirth Lack of estrogen Pelvic surgery Obesity


Urge Incontinence

Abrupt desire to void which cannot be suppressed

Common in women and the elderly

Causes:

The majority of cases are idiopathic

Infection, tumor, stones, urethritis, stroke, Parkinson’s Disease, dementia

厕所-- 那么近

-- 却那么远

厕所-- 那么近

-- 却那么远


Overflow Incontinence

The uncontrollable leakage of small amount of urine from a overfilled and enlarged bladder

Bladder outlet obstruction BPH, fecal impaction

Non-contractile bladder diabetes, spinal injury, medications


Functional Incontinence

mental or physical disabilities to control urinating, the urinary system itself is normal.

Conditions that can lead to functional incontinence : Parkinson's disease

dementia

Mental confusion may prevent both recognition of the need to void and locating a bathroom.

Severe depression


Fluid Intake

Age

Health Status and treatment

Emotional Status

Others

Factors Affecting Urination


Fluid Intake

Fluid Homeostasis

Input = output Caffeine promotes urine formation Alcohol inhibits ADH Fever causes diaphoresis


Age

Young Control of urination begins between 2 to 3 years of

age Nighttime : cannot control till age 4 or 5

Elderly Mobility problems Chronic neurological problems Changes in kidney and bladder function


Health Status

Diseases

Peripheral nerve lesions Loss of bladder tone

Reduced sensation

Difficulty in control

Physical disability Difficult to reach/use toilet


Surgery Stress of surgery

Triggers General Adaptation Syndrome Increased ADH Elevated aldosterone

Anesthetic analgesics Slows glomerular filtration rate Impairs sensory and motor impulses

Lower abdominal and pelvic area surgery Edema and inflammation

Health Status


Medications Prevent reabsorption

Diuretics

Urinary retention Anticholinergics Antihistamines Antihypertensives

Color change

Toxic to kidneys

Health Status


Emotional Status

AnxietyStress

Urgency Frequency Muscle tension

Difficult to relax abdominal and perineal muscles


Other factors

Social cultural norms Privacy environment Facilities

Habits Proper positioning

Climate


Nursing interventions for urination

Urinary Retention

Urinary Incontinence


Interventions for Urinary Retention patient

Privacy environment

Normal position

Sensory stimuli

Muscle relaxing

Health education

habits ： time voiding

Medications

灌肠 / 排便诱导排尿Catheterization

Squatting for female

Standing for male

Running waterHand in waterWarm the bedpan

耻骨上膀胱区热敷或针灸


Maintain skin integrity, promote comfort

External drain the urine

Restore normal micturition

Interventions for Urinary incontinence patient

Offer fluid: 2000-3000 ml/day

Bladder Retraining: Take to bathroom q1-

2H

Pelvic floor muscle training, PFMT(Kegel's

)

CatheterizationPsychological support

收缩与放松盆底肌群开始各持续 2 秒，重复 15次， Tid每周增加 1 秒收缩与放松时间，至10 秒维持 10 秒，重复 10 次， Qd


Catheterization

Plastic, rubber or silica gel tube through urethra into bladder

Continuous flow of urine Assess hourly urine output Medication therapy

Nursing skills for urination


Catheterization

Types

Intermittent Catheterization Insert long enough to drain bladder

Repeat PRN

Indwelling Catheterization Stays in place Change periodically


Indications

Intermittent urinary retention--

Relieve bladder distention

Obtain urinary specimen

Assess residual

Long term management of spinal cord injury

Indwelling Obstruction

Surgery （ pelvic area 、 Urinary system ）

Measure I&O in critically ill

Urinary incontinence and Severe retention

Terminally ill with trouble moving


Care and Removal

Care---Maintain flow and prevent infection

Sterile Maintain closed system Hang lower than bladder Clean with soap and water at least Qd

Area and tube After each BM (bowel movement)

Maintain fluid intake

Removal of indwelling catheter Promote normal bladder function Prevent trauma Need order--Explain, empty, remove


Nursing Implications to Urine Tests

All specimens must be labeled with name, date and time of collection

Transported in time If unable, refrigerate

Wear gloves

Nursing skills for urination


Common Urine Tests

Random

Midstream

Timed

Clean, not sterile

Don’t contaminate with stool

Specific gravity; pH;

Glucose

Test renal function and urine composition

12 or 24 hours

Creatinine clearance,

protein

Catheterized

Culture and sensitivity


Words

Urinary Elimination Kidney Ureter Bladder Urethra Oliguria Anuria Polyuria Frequency urination Urge urination

Dysuria Stress Incontinence Overflow Incontinence Urge Incontinence Functional Incontinence Retention of urine Intermittent Catheterization Indwelling Catheterization Bladder Irrigation


了解：与排尿有关的解剖与生理。熟悉：影响排尿的因素。掌握：掌握对排尿活动的评估及护理。

教学目标

王克芳 [email protected] 0531-88382201 山东大学护理学院 Elimination.

Documents