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Altered Elimination.docx

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NURS 2090
Heather Helpard

Altered Elimination Urinary Elimination • Urine production ◦ Process: excreted via a complex interplay btw neural, motor and hormones ◦ Elimination: needs to be patent! Renal Processes: 1. Regulation of body fluid volume and composition 2. Elimination of metabolic wastes 3. Synthesis, release and/or activation of hormones a. Erythropoietin (hormone for red cell production) b. Renin (converts Angio I to Angio II, stimulating aldosterone secretion) c. Vitamin D (secreted by kidneys to stimulate calcium absorption in the GI) 4. Regulation of blood pressure (RAAS) Urine Production: • Nephron: Role is to filter water soluble substances in blood, Reabsorb nutrients, secrete waste  Renal blood flow makes up 20-25% cardiac output (1000 ml blood/minute)  Urinary filtrate  Enters the Bowman’s capsule through the tubule system  Transport via countercurrent mechanism (vasa recta is a capillary that moves in the opposite direction of the filtrate in the tubule).  Excreted as urine Cortex: glucocorticoids Medulla: NE/E Substance Filtration Site Passive Reabsorption Active Reabsorption Sodium glomerules Potassium glomerules Proximal tubule Thick ascending loop of Henle Chloride glomerules Late proximal and distal tubule Proximal tubule, ascending LoH, distal convoluted tubule Hydrogen *secreted actively in Proximal convoluted tubule proximal, distal convoluted and collecting tublues Bicarbonate glomerules Proximal and distal convoluted tubule Glucose glomerules Completely reabsorbed by active mechanisms unless tubular maximum is exceeded Urea glomerules Proximal, late distal and collecting duct Calcium glomerules Proximal tubule and thin LoH Ascending thick LoH and early distal convoluted tubule Phosphate glomerules Proximal tubule Magnesium glomerules Ascending thick LoH Ascending thick LoH Uric Acid glomerules Early and late proximal tubule Protein glomerules (limited) Proximal distal tubule by AAs Urine Removal:  Transport of urine: Ureters are composed of smooth muscle fibers that propel urine to bladder via peristalsis. (urine enters bladder via the trigone, which serves as a sphincter to prevent urine from moveing back into the ureter from bladder)  Bladder filling:  Activates stretch receptors  Signal stimulates contraction of detrusor skeletal muscle via parasympathetic cholinergic motor fibers  Relaxation of internal and external urethral sphincter results in micturition  Spinal cord injury S1-S2: worried about bladder control Urinary Excretion Urine Characteristics:  Yellow: Dark amber may indicate dehydration (color is from urochrome pigments)  Clear: Cloudy may indicate infection (due to increased protein)  Slight ammonia odor  Total volume: 750-2000 mL/day  Dehydration: dark, strong smelling urine UrineAnalysis: 1. Macroscopic: Color, clarity 2. Biochemical: urine dipstick: pH, specific gravity ( ↑concentration = dehydration), protein (anorexia, muscle wasting, kidney disease), glucose (diabetes), ketones, nitrite (protein metabolism, diseased kidney), leukocyte esterase 3. Microscopic: Crystals, casts, squamous cells, white and red blood cells, bacteria Urine should be free of protein, glucose, ketones, nitrate, bacteria, leukocyte esterase, crystals, stones, and casts (structures of a protein meshwork of entrapped cells- usually sloghed off WBC) **Epithelial cells may be present in small numbers Altered Urinary Elimination 1. Altered motility: Reduced contraction of hollow structures  Filtrate could stop in the renal tubules or bladder, which may make casts form due to low flow rate, ↑ Na concentration, low pH (all favor precipitation= blockage= altered reabsorption/secretion)  Glmerulonephritis: trapping of RBC’s in the casts  Acute tubular necrosis: epithelial cells may indicate sloughing of tubular cells.  Pyelonephritis: WBCs sloughing  Decreased movement of filtrate also promotes bacterial growth + kidney infection Acute Tubular Necrosis 2. Altered neuromuscular function: (leads to urinary retention or incontinence)  May involve neurons in PNS/CNS, NT, coordination of impulses  Failure to provide appropriate stimulus for response = little/absent ability to urinate.  Failure or exaggerated neural signal transduction  Failure of appropriate muscle response  Peristalsis in the renal tubules, contraction/relaxation of muscles, conscious control 3. Altered perfusion: Inadequate blood supply results in ischemia and infarction  May be due to constriction, inadequate vascular volume, obstruction  Loss of functional tissue through necrosis results in pain, bleeding, obstruction  Enhanced perfusion results in increased work load and stress  Focal: local  Global: systemic 4. Altered patency: Blockage of structures (obstruction)  Consequences of obstruction related to: degree of obstruction, duration, chronicity  Obstructions have a buildup of pressure behind the obstruction, which leads to structural damage.  Dilation of structures proximal to obstruction lead to infection and structural damage  Hydroureter: accumulation of fluid in the urinary ureter, which is a consequence of a complete obstruction.  Hydronephrosis: when the pressure builds up to the renal pelvis and tubules, leads to decreased GFR, and renal impairment. Fluid escapes to the surrounding capillary system Herpes Simplex II can lead to UTIs which will lead to scar tissue causing obstructions/this narrows ureters causing urine to back up into the kidney creating hydronephrosis and vascular death which may caus pt to lose kidney Altered Urinary Elimination Clinical Manifestations:  Altered urinary volume (may be increased due to hormones/decreased)  Altered urinary composition (reflects pathology)  Pain (renal transmits to SC @ T10-L1, most pain stimulated by stretching and inflammation in the renal capsule = dull, persistent pain. Descending urinary system = sharp and intermittent.  Bleeding (hematuria), distention,  Anorexia, NV  General malaise  Fever Ascending infection through the ureters into the kidneys represents the renal structural damage. Condition Description Etiologies Proteinuria Protein in urine Renal failure, nephritic syndrome preeclampsia, renal artery/vein thrombosis, glomerular disease, tubalopathy Glucosuria Glucose in urine Diabetes Ketonuria Ketones in urine Diabetes, ketoacidosis Hematuria RBCs in urine Starvation, glomerular damage, tumors, kidney trauma, UTI, acute tubular necrosis Pyuria WBCs in urine Urinary tract obstruction, UTI, acute glomerularnephritis Bacteruria Bacteria in urine Renal calculi, UTI Diagnosis:  Macro- and microscopic urinalysis  Imaging studies: 1. Intravenous Pylogram (IVP): radiocontrast medium injected to visualize kidneys, ureters and bladder 2. Voiding Cystourethrogram (VCUG): xray examination of the bladder and urethra completed after insertion of contrast into bladder via urinary catheter 3. Renal Angiogram: contrast injected into renal artery via the aorta to diagnose renal artery stenosis or intrarenal vescular obstructions 4. Renal Ultrasound: determines kidney size, cysts, obstructions, or fluid collection Treatment:  Underlying cause Bowel Elimination:  Function of the gastrointestinal system- GI system does not change with aging  Blood supplied by superior and inferior mesenteric arteries  Autonomic nervous system innervation Bowel Elimination  Large Colon Components: Cecum,Appendix, Colon, Rectum,Anal canal  Large Colon Divisions: Ascending, Transverse, Descending, Sigmoid Important to note the difference between an illeostomy and a colostomy and what the stool will look like in each (illeostomy- stool is watery/ colostomy- stool is bulky)  The ileocecal valve joins the ileum of the small intestine, to the cecum of the large intestine and directs the flow of fecal matter from the small intestine into the large. (18 hours to travel distance of lg int.)  Greatest concentration of GI bacteria (intestinal flora) resides in the large colon (mostly anaerobic organisms) and these help to break down remaining dietary fiber and protect intestine from pathogens  Colon gets narrower in diameter as it travels along each area (H20 reabsorption occurs here and fiber is of vital importance)  Abdominal pain and distension are important to moniter. The enteric NS controls movement and elimination and should be constantly moving otherwise it can back up and you will vomit poo.  The greatest absorption of nutrient occurs in the small intestine, but the large intestine provides the final opportunity for achievement of H2O and electrolyte balance Gastrointestinal Structures Stool Elimination:  Fecal matter entry  After absorption, feca
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