The kidneys form the urine.

The ureters carry urine to the bladder.

The bladder acts as a reservoir for the urine.

The urethra is the passageway for the urine to exit the body.

Anatomic integrity of the urinary system

Nervous control of the detrusor muscle

Competent sphincter mechanism

Uncontrolled loss of urine 

Abnormalities of one or more factors

Normal glomerular function- Urine formation starts at glomerulus where blood is filtered

GFR-(Glomerular filtration rate)- amt of blood filtered by glomeruli in a given time

Normal GFR- 125ml/minute, however only 1 ml per minute becomes urine, most is reabsorbed

Kidneys 

Nephrons

Parenchyma

Hilus of kidney

Renal pelvis

Ureter

Bladder

Detrusor (smooth muscle bundles in the upper portion of the bladder)

Urethra (sphincter mechanism)

Pelvic muscles (slow-twitch fibers and fast-twitch fibers)

Urine travels from the bladder through the urethra & passes outside the body through the urethral meatus

Lined by mucus membranes, bacteriostatic, forms mucus plug

Women-1.5-2.5 inches (4-6cm) long, external sphincter allows voluntary flow of urine, prone to infection

Men-Urethra is both a urinary canal and a passageway for secretions form reproductive organs

8 inches (20cm) in length

Central nervous system

Peripheral nervous system

Sympathetic nervous system

Parasympathetic nervous system

Micturition (peeing) center

Urethral compression

Bladder filling

Urinary storage

Urethral tension

Supportive structures

Coordination of cerebral cortex, thalamus, hypothalamus, & brain stem

Normally holds about 600ml

Desire to void when bladder contains a smaller amount (150-200ml in adult)

As bladder volume increases, bladder walls stretch, sending sensory impulses to micturition center

Disease

Growth & Development

Sociocultural factors

Psychological Factors

Muscle Tone

Fluid Balance

Surgery

Medications

Infants & young children cannot effectively concentrate their urine

Older adult: difficulty with urination, GFR declines. Kidney’s ability to concentrate urine declines

Nocturia, urinary frequency

BPH in men

Residual urine (UTI’s)

Private toilet facilities (American) communal (Europe)

Social expectations influence time of urination

Must consider cultural, social and gender habits

Anxiety and emotional stress may cause sense of urgency and increase frequency of urination

Need to relax to void

Weak abdominal & pelvic floor muscles impair bladder contraction and control of external sphincter

Prolonged immobility, stretching of muscles, menopausal muscle atrophy, damage from trauma, long term catheter use

Ingested fluids increase body’s circulating plasma volume which increase urine output

Increased urine formation: coffee, tea, cola drinks 

Caffeine is a bladder irritant as well as a diuretic

Alcohol inhibits the release of ADH resulting in increased water loss in urine

Triggers General Adaptation Syndrome ( Increase water reabsorption, reduces urine output

Stress response causes increased aldosterone resulting in decreased urine output

Anesthetics & narcotics slow GFR decreasing urine output, risk for urinary retention with spinal anesthesia (post-op patients may require hourly urine outputs or if unable to void after surgery, straight catheterization)

Diuretics prevent reabsorption of water and certain electrolytes to increase urine output

Urinary retention caused by antihistamines (Sudafed), antihypertensives (Aldomet), & beta blockers (Inderal)

Change color of urine-Pyridium

Urinary Retention

Urinary Tract Infections

Urinary Incontinence

Urinary Diversions

Marked accumulation of urine in bladder as a result of the inability of the bladder to empty

Bladder not able to respond to micturition reflex and empty

Retention with overflow may develop, small amt of urine escapes, bladder spasms

S&S of bladder distention- discomfort, diaphoresis, restlessness

7 million office visits a year

Most common nosocomial infection on U.S.

Most from catheterization or surgery

Bacteria in the urine may lead to the spread of organisms into bloodstream (Urosepsis)

Pain or burning on urination (dysuria)

Fever, chills, n/v, malaise (later signs)

Hematuria-irritation of bladder & urethral mucosa resulting in blood-tinged urine

Pyelonephritis-infection spreads up to kidney-flank pain, fever

Functional

Overflow

Reflex

Stress

Urge - oversensivity

Urethral blockage

Bladder unable to empty

Relaxed pelvic floor

Increased abdominal pressure

Bladder oversensitivity from infection

Neurologic disorders

Urinary stoma to divert urine from kidneys directly to abdominal surface

Ileal Conduit

Continent Pouch – must be catheterized every q hrs.

Ureterostomy

Nephrostomy

Cancer (Bladder, Prostate, Pelvis, Cervix)

Radiation injury

Vesicovaginal fistula

Neurogenic bladder

Chronic cystitis

Painful Bladder Syndrome/Interstitial Cystitis

History

Physical Assessment

Assessment of Urine

Diagnostic Tests

Invasive

KUB

IVP 

renal ultrasound

renal CT scan

cystoscopy

arteriogram

urodymanics

Initiate pelvic muscle exercise regimen

Bladder training for urge incontinence

Management of urinary retention

Management of functional urinary incontinence

Suggest environmental modifications

Random

Clean-voided or midstream

Sterile

Timed specimens (24 hour collection)

Uninalysis

Specific Gravity

Urine Culture

Incontinence

Self-Care deficit

Skin Integrity

Altered Urinary Elimination

Pain

Body Image Disturbance

Promoting Normal Micturition

Medications

Catheterization (Indwelling vs. straight)

Catheter Irrigations & Instillations

Routine Catheter Care/Perineal Care

Suprapubic Catheterization – 

External Urinary Cathethers (Condom caths)

Female Urinals

Maintaining Skin Integrity

Preventing Infection

Continence

Structures of the Gastrointestinal Tract 

Intestinal Motility and Rectal Accommodation

Anal Sphincter Mechanism

Consistency of the stool (fecal material)

Intestinal motility

Compliance and contractility of the rectum 

Competence of the anal sphincters

Small intestine

Ileocecal valve

Large bowel (colon)

Ileocecal sphincter

Anal sphincter

Rectal filling 

Rectal contractions

Rectal accommodation – from “holding it”

Postponement of defecation

Constipation

Internal and external sphincters

Striated muscle fibers

Sensory receptors

Age

Diet

Exercise

Medications

Type 1: Separate hard lumps, like nuts (hard to pass)

Type 2: Sausage-shaped, but lumpy

Type 3: Like a sausage but with cracks on its surface

Type 4: Like a sausage or snake, smooth and soft

Type 5: Soft blobs with clear cut edges (passed easily)

Type 6: Fluffy pieces with ragged edges, a mushy stool

Type 7: Watery, no solid pieces. Entirely liquid

Diverticular disease

Neuropathic conditions

Functional limitations

Irregular defecation habits

Laxative abuse/enema abuse

Psychological stress

Diet

Fluid intake

Age

Disease processes

Bowel obstruction

Vagal Response

Fecal impaction

Hemorrhoids

Bolus of hardened stool

Further slows colonic transit time and passage of further fecal contents

Malabsorption syndromes

Inflammatory bowel disease

Short bowel syndrome

Side effects of drugs

Laxative or enema misuse

Infectious diarrhea is caused by a pathogen

Decreased amt of swallowed air:

Carbonated beverages, Straws, Gum, Hard candies

NGT for decompression of abdomen

Dysfunction of the anal sphincter

Disorders of the delivery of stool to the rectum

Disorders of rectal storage

Anatomic defects

Age, Diet

Fluid Intake

Mobility/Immobility

Psychological Consideration

Life-style Considerations

Medications

Diagnostic Procedures

Anesthesia and Surgery

Pathologic conditions

Irritants

Pain

History

Physical Examination

Diagnostic and Laboratory Data

Elimination habits

Type of incontinence

Complicating factors

Bladder and bowel management strategies used by client

Mental status

Mobility and dexterity

Inspection of perineum for skin integrity

Inspection of vaginal vault 

Pelvic support

Perineal sensation

Perianal area, digital rectal exam

Urinalysis

Stool culture

Defecography

Anorectal ultrasonography

Constipation

Perceived Constipation

Diarrhea

Bowel Incontinence

Low Self-Esteem

Deficient Knowledge

Risk for Infection

Risk for Impaired Skin Integrity

Toileting Self-Care Deficit

Fluid intake

Diet

Alcohol and tobacco use

Stress management

Weight reduction

Elimination habits

Positioning

Over the Counter (OTC)

Prescription 

Cleanse the lower bowel

Assist in evacuation

Instill medication

Client’s level of maintenance or restoration of elimination patterns and return to an appropriate level of independence

Prevention of skin breakdown and infection 

Client understanding of procedures and self-care