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Urinary Elimination

Urinary Elimination

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Published by Marcus, RN
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Published by: Marcus, RN on Sep 21, 2008
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Urinary Elimination
1.
Anatomy of the urinary tract
 a.
divided into four parts:
 i.
kidneys
 a.
two reddish-brown, bean-shaped organs located on either side of the vertebral column behind the abdominal peritoneum and against the deepmuscles of the back
 b.
each kidney has its own blood supply
 1.
one renal artery
 a.
originates in the abdominal aorta
 b.
enters the kidney at the hilum
 2.
one renal vein
 a.
exits the kidney through the hilum
 b.
 joins the inferior vena cava
 c.
each kidney has over 1,000,000 nephrons, its functional unit that filters waste products from the blood and regulates fluid and electrolyteconcentrations in the body fluids, which are composed of six parts
 1.
glomerulus
 2.
Bowman
s capsule
 3.
proximal convoluted tubule
 4.
loop of Henle
 5.
distal convoluted tubule
 6.
collecting duct
 ii.
ureters
 a.
two tubular structures attached to each kidney pelvis which carry urine from the kidneys into the bladder
 b.
length of the ureters
 1.
25 to 30 centimeters (10 to 12 inches) long
 c.
a small, flaplike fold of mucous membrane covers the junction of the ureters and the bladder and acts as a valve to prevent urinary reflux (backflow)
 iii.
bladder
 a.
a hollow, distensible, muscular organ that is a reservoir for urine
 b.
composed of three parts
 1.
detrusor muscle
 a.
composed of three layers of smooth muscle
 i.
inner; longitudinal
 ii.
middle; circular
 iii.
outer; longitudinal
 2.
the trigone (a triangle-shaped area located at the base of the bladder)
 a.
the ureter openings at the posterior corners form the base of the triangle
 b.
the opening of the urethra at the anterior inferior corner forms the apex of the triangle
 3.
internal urinary spinchter (involuntary control; sits at the base of the bladder)
 iv.
urethra
 a.
a tubular structure attached to the bladder that carries urine from the bladder to the urinary meatus and outside of the body
 b.
length of the urethra
 1.
women: 3.7 centimeters (1.5 inches) long
 2.
men: 20 centimeters (8 inches) long
 a.
consists of three parts
 i.
prostatic
 ii.
membranous
 iii.
cavernous
 b.
important in renal and reproductive functioning
 i.
carries urine outside the body
 ii.
carries semen outside the body
 c.
external urinary spinchter (voluntary control) sits at the base of the urethra
 2.
Process of urine production
 a.
glomerular filtration
 i.
blood enters the glomerular capillaries and is filtered in the following ways:
 a.
red blood cells and protein molecules are too big and cannot pass through the glomerular capillaries out of the glomerulus and into Bowman
scapsule and, consequently, stay in the bloodstream
 b.
all other constituents of the plasma pass through the glomerular capillaries out of the glomerulus and into Bowman
s capsule and, consequently,become what is known as the glomerular filtrate
 ii.
rate of formation of glomerular filtrate
 a.
25 milliliters a minute
 b.
180 liters daily
 b.
tubular reabsorption
 i.
as the glomerular filtrate passes through the tubules, substances that the body wants to retain are actively and passively reabsorbed, e.g.:
 a.
water
 b.
electrolytes (sodium, potassium, chloride, bicarbonate)
 c.
glucose
 d.
amino acids
 ii.
about 99% of the glomerular filtrate is reabsorbed by the tubules
 iii.
the remaining 1% of the glomerular filtrate that is not reabsorbed by the tubules forms the fluid waste called urine
 c.
tubular secretion
 i.
the tubules also secrete some substances into the glomerular filtrate to remove them from the body, e.g.:
 a.
hydrogen ions
 b.
potassium ions
 
 
c.
ammonia
 d.
creatinine
 e.
uric acid
 3.
Process of urinary elimination (voiding; micturation)
 a.
usually occurs when the volume of urine in the bladder reaches about 250 to 450 milliliters
 i.
pressure of that amount of urine stimulates sensory nerve fibers in the detrusor muscle called stretch receptors
 ii.
these stretch receptors transmit their sensory impulses through pelvic nerve fibers to the voiding reflex center located in the sacral 2 - 4 segments of thespinal cord
 iii.
these fibers then synapse through interneurons to the anterior portion of the spinal-cord at that level
 iv.
motor impulses are then transmitted from the anterior root of the sacral 2 - 4 segments of the spinal cord through parasympathetic nerve fibers by way of thepelvic nerve back to the detrusor muscle causing it to contract and open the internal urinary spinchter
 v.
the individual perceives the need to void and finds a toilet
 vi.
the individual inhbits the external urinary spinchter voluntarily through a similar reflex arc described above by way of pudendal nerve fibers
 vii.
voiding occurs
 4.
Factors influencing urinary elimination
 a.
age
 i.
children
 a.
desire to control daytime urinary elimination occurs when a child becomes aware of the following (usually around 2 years old):
 1.
discomfort of a wet diaper
 2.
sensation that indicates need for elimination of urine
 b.
nurses can become involved in a child
s toilet training in the following ways:
 1.
continuing the toilet training program established at home while the child is in the hospital
 2.
educating parents on methods for successful toilet training, such as providing their child with the following:
 a.
clothes that can be removed independently
 b.
a personal toilet seat
 c.
sufficient time to eliminate urine
 d.
a consistent, relaxed atmosphere
 e.
praise for successful behavior while avoiding punishment for unsuccessful behavior
 f.
a non-stressful period in which to initiate toilet training
 ii.
elderly
 a.
changes in the elderly that can effect urinary elimination include the following:
 1.
30 to 50% decrease in the number, size, weight, and function of the nephrons and, consequently, the size and weight of the kidney
 2.
decreased renal blood flow and, consequently, glomerular filtration rate
 3.
decreased reabsorptive and secretory capabilities of the renal tubules and, consequently, ability to concentrate urine
 4.
decreased muscle tone and contractility of the detrusor muscle and, consequently, ability to empty bladder without leaving residual urine anddifficulty starting the urinary stream
 5.
decreased innervation of the detrusor muscle and external urinary spinchter and, consequently, ability to maintain urinary continence
 b.
fluid intake
 i.
intake of increased or decreased amounts of fluid can effect urinary elimination in the following ways:
 a.
increased fluid intake increases urine production and elimination by inhibiting the release of anti-diuretic hormone (ADH) which inhibits reabsorption ofwater in the renal tubules
 b.
decreased fluid intake decreases urine production and elimination by facilitating the release of ADH which facilitates reabsorption of water in the renaltubules
 ii.
intake of certain types of fluids can adversely effect urinary elimination, such as the following:
 a.
alcohol, caffeine
 1.
increase urine production and elimination by inhibiting the release of ADH which inhibits reabsorption of water into the renal tubules
 b.
fluids containing sodium
 1.
decrease urine production and elimination by providing an increased amount of sodium in the glomerular filtrate which facilitates water, alongwith the sodium, to be reabsorbed by the renal tubules
 c.
food intake
 i.
intake of certain foods can effect urinary elimination in the following ways:
 a.
increase urine production and elimination if high in fluid content
 1.
e.g., fruits, vegetables, cooked cereal
 b.
decrease urine production and elimination if high in sodium content
 1.
e.g., potato chips, cheese, pickles
 c.
change the color of the urine
 1.
e.g., beets, blackberries may turn urine red
 2.
e.g., carrots (beta-carotene) may turn urine yellower than ususal
 d.
medications
 i.
certain medications can effect urinary elimination in the following ways, e.g.:
 a.
cholinergics
 1.
stimulate contractions of the detrusor muscle which may facilitate urinary elimination, e.g.:
 a.
bethanechol chloride (Urecholine)
 b.
anticholinergics
 1.
inhibit contractions of the bladder and detrusor muscle which may lead to urinary retention, e.g.:
 a.
atropine sulphate
 b.
hyoscine
 c.
homatropine methylbromide
 d.
scopolamine
 e.
hyoscyamine
 c.
opioid analgesics
 1.
increase tone of the detrussor muscle and external urinary spinchter and suppress awareness of bladder distention which may lead to urinaryretention, e.g.:
 a.
morphine sulphate
 b.
meperidine hydrochloride (Demerol)
 c.
codeine
 d.
hydromorphone (Dilaudid)
 
 
e.
propoxyphene (Darvon)
 d.
diuretics
 1.
increase urine production primarily by preventing reabsorption of sodium and, consequently, water in the renal tubules, e.g.:
 a.
chlorothiazide (Diuril)
 b.
hydrochlorothiazide (HydroDiuril)
 c.
furosemide (Lasix)
 d.
spironolactone (Aldactone)
 e.
triamterene (Dyrenium)
 e.
can change the color of the urine
 1.
to red, e.g.:
 a.
methlydopa (Aldomet)
 2.
to orange, orange-red, or pink, e.g.:
 a.
phenazopyridine (Pyridium)
 b.
phenytoin (Dilantin)
 c.
rifampin (Rifadin)
 d.
warfarin sodium (Coumadin)
 3.
to green or blue-green, e.g.:
 a.
amitriptyline (Elavil)
 b.
indomethacin (Indocin)
 c.
B-complex vitamins
 4.
to brown or black, e.g.:
 a.
levodopa (L-Dopa)
 b.
iron preparations, e.g.:
 i.
ferrous sulphate (Feosal)
 ii.
ferrous gluconate (Fergon)
 iii.
ferrous fumarate (Feostat)
 e.
activity
 i.
inadequate activity can effect urinary elimination
 a.
decreases the tone of the abdominal muscles which can result in a decreased amount of intra-abdominal pressure that can be exerted on thedetrusor muscle during voiding
 b.
decreases the tone of the pelvic floor muscles which can result in a decreased ability of the external urinary spinchter to hold back the flow of urinewhen placed under pressure
 f.
psychologic factors
 i.
certain emotional states can effect urinary elimination
 a.
anxiety/stress activates the sympathetic portion of the autonomic nervous system (ANS) which inhibits detrusor muscle contractions and increasesthe tone of the internal urinary spinchter which can potentially lead to urinary retention
 g.
life-style
 i.
certain life-style behaviors can effect urinary elimination by delaying voiding which can stretch and weaken the detrusor muscle and lead to incompleteempyting of the bladder, residual urine left in the bladder, and bladder infections such as the following:
 a.
ingnoring the urge to void
 1.
insufficient time
 2.
unavailability of toilet facilities
 3.
lack of privacy
 b.
inability to assume a normal position
 h.
diagnostic procedures
 i.
cystoscopy can effect urinary elimination in the following way:
 a.
precipitate edema of the urethra which may obstruct the flow of urine and can result in urinary retention
 i.
anesthesia and surgery
 i.
general, spinal, and epidural anesthesia, and concomittant use of general and regional anesthetic agents, can effect urinary elimination in the followingways:
 a.
decrease blood pressure, rate of glomerular filtration and, consequently, urine production and elimination
 b.
effect innervation of the detrusor muscle and internal urinary spinchter which can result in urinary retention
 ii.
surgery on any part of the urinary tract, intestines, and/or reproductive organs can effect urinary elimination by preciptitating the following:
 a.
edema and/or bleeding which may obstruct the flow of urine and can result in urinary retention
 b.
negative imbalance between intravenous fluid intake and fluid and blood loss which can result in decreased blood pressure, rate of glomerular filtrationand, consequently, urine production and elimination
 c.
release of ADH as part of the stress response
  j.
pathologic conditions
 i.
pathologic conditions can effect urinary elimination in the following ways:
 a.
decrease or eliminate innervation of the detrusor msucle and internal and external urinary spinchters which can result in urinary incontinence, e.g.:
 1.
spinal-cord injury, cerebral vascular accident (CVA), multiple sclerosis
 b.
decrease physical mobility and, consequently, ability to reach a toilet or bedside commode in time and/or assume a normal position for voiding, e.g.:
 1.
rheumatoid arthritis, degenerative joint disease, multiple sclerosis
 c.
decrease the cognitive ability to consciously control voiding, e.g.:
 1.
CVA, Alzheimer
s disease, Parkinson
s disease
 d.
alter the release of hormones that influence the production and elimination of urine, e.g.:
 1.
syndrome of inappropriate antidiuretic hormone (SIADH)
 a.
results in the inappropriate release of ADH and decreased urine production and elimination
 2.
diabetes insipidus
 a.
results in inhibition of the release of ADH and greatly increased urine production and elimination
 3.
aldosteronism
 a.
results in excessive release of aldosterone (which facilitates reabsorption of sodium and, consequently, water from the renal tubules)and decreased urine production and elimination
 e.
decrease the blood supply to the kidney, rate of glomerular filtration, and urine production and elimination, e.g.:
 1.
arteriosclerosis; shock; massive diarrhea, vomiting, and dehydration
 f.
obstruct the flow of urine which can result in urinary retention, e.g.:
 1.
strictures of the ureters or urethra, benign prostatic hypertrophy, urinary tumors or other tumors that press against the urinary tract, urinary

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