Elimination Patterns: Bladder

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1 Elimination Patterns: Bladder CRRN Review Material Christa Carter, RN, BSN, CRRN Objectives Identify different types of neurogenic bladder Identify different types of incontinence Identify at least three signs and symptoms of autonomic dysreflexia Identify at least two common causes of autonomic dysreflexia Anatomy Innervation Upper Urinary Tract Kidneys Filter waste products from the blood Maintain acid base balance Produce Urine Ureters Tubes to transport urine from kidneys to bladder Lower Urinary Tract Bladder Also known as the detrusor Made of 2 smooth muscles: the detrusor and the trigone Base of the bladder has an internal and external sphincter (the external sphincter is voluntarily controlled) Urethra What connects the bladder to the outside of the body Parasympathetic Controls involuntary movement rest and digest Initiates bladder contraction and controls the transport of urine to the ureters Sympathetic Controls the stress response in muscles fight or flight Can slow down transport of urine to ureters and tighten the internal sphincter Somatic Controls voluntary movement Can transmit sensory responses Stimulates contraction or relaxation of external sphincter or pelvic floor in women Signal Abnormalities Brain Stroke Brain tumor Traumatic brain injury (TBI) Multiple Sclerosis Dementia Parkinson s disease Spinal Cord Injury (SCI) Damage to S2 S4 can lead to sacral bladder Image of bladder nerve innervation *Pudendal nerve is part of the somatic nervous system. 1

2 Bladder signals it s full at typically ml Message is relayed to the brain stem. Brain stem then decides whether to ignore the message (hold it) or act (void). If the decision is to void, the brain stem sends a message to the sphincter, then the bladder. The bladder contracts. Sacral spinal cord receives the message and passes it on to the brain stem. The sphincter relaxes. Urine is released. (image) Sacral Spinal Cord S2, S3, and S4 relay messages from the bladder to the sacral spinal cord and back. This is the reflex voiding arc. How infants void: bladder fills, signals it s full, and empties. The reflex voiding arc can be disrupted in injuries to the Cauda Equina. Brain Stem Determines whether it is socially appropriate to void. Can send messages to both the bladder and the sphincter. Changes With Age Infants Complex reflex arc sacral arc controls voiding Bladder fills, bladder empties Toddlerhood Somatic nervous system develops allowing for voluntary control of the reflex arc Bladder fills > bladder signals its full > brain signals whether its appropriate to void > bladder empties Changes with Age Middle childhood to adolescence The pelvic floor muscles strengthens In girls, estrogen is released which strengthens the pelvic floor muscles In boys, prostate gland grows 2

3 Changes with Age: Adulthood Changes with Age: Adulthood Men Prostate gland enlarges with age which can cause pressure on the urethra or stress the bladder. Women Pelvic floor can become weak temporarily or permanently with childbirth Decreased estrogen, causing a weakening of the pelvic floor and vaginal muscles A weakened pelvic floor can lead to incontinence Overactive bladder When the bladder contracts too frequently and involuntarily Can effect both men and women Incontinence Incontinence Understand the cause of incontinence before initiating a treatment plan Urge Caused by instability or overactivity of the bladder Can also be caused by Detrusor Sphincter Dyssynergia (DSD) This is where the bladder contracts but the sphincter does not relax completely to allow the emptying of the bladder Stress Loss of urine during activity (ie coughing, laughing, sneezing or increased abdominal pressure) Overflow Exhibited by dripping from the urethra Typically seen with an over distended bladder caused by no contraction of the bladder or a urinary obstruction Incontinence Transient Once the cause is addressed, transient incontinence typically resolves Secondary to: Disorders: endocrine conditions, CHF, sleep apnea, UTI, inflammation of the urogenital area, over hydration, depression, delirium, constipation, dehydration Medication Restricted mobility Interventions Voiding strategies Timed voiding: typically every 2 hours Habit training: sets up voiding schedule based on patient s previous habits Prompted voiding: includes positive reinforcement for episodes of continence Bladder retraining Put into place after continence is established Teaches relaxation techniques to use during instances of urges to void Instructs patient to do the following stop or decrease use of caffeine and aspartame Drinking 6 8 glasses a day of other liquids Stop drinking liquids at least 2 hours prior to bed time 3

4 Interventions Kegel exercises Contraction of the puboccygeal muscle Pulling the vagina, rectum and urethra inward Teaching includes stopping urine flow Should be held for a 10 count and done for 10 minutes three times a day Pelvic Muscle rehabilitation Vaginal weight training Biofeedback; censors are placed so patient can see when contractions are effective Interventions Medications Alpha adrenergic agonists (Tizanidine/Flomax) Anticholinergics (Ditropan, Detrol) Antispasmodics Conjugated Estrogen Surgical Interventions The type of surgery depends on the type of problem. Bladder enlargement for detrusor instability Removal of obstructions for overflow incontinence Urinary Retention Caused by Spinal Cord Injury Enlarged prostate Neurogenic bladder Urinary tract infections Interventions Empty the bladder Straight intermittent catheterization Suprapubic catheterization Foley catheterization Spinal Cord Injuries Spinal Shock Condition that takes place directly after an SCI Leads to loss of all reflexes below the level of injury The bladder does not empty when full Can lead to autonomic dysreflexia (AD) When noxious stimuli causes the autonomic nervous system to react Can signal a return in reflexes after spinal shock Can be caused by any noxious stimuli, but most commonly is caused by bladder distention Is a medical emergency Hypertension Bradycardia Fast, major increase in Tachycardia blood pressure Pounding headache Flushing above the level of injury Goose bump Blurry vision or seeing Sweating above the level spots of injury Chest tightness Cold, clammy skin below the level of injury Restlessness Nasal congestion Anxiety Jitters or a feeling of impending doom (NSCIA, 2013) 4

5 Assess for bladder distention This is the most common cause for AD Assess for bowel impaction ONLY assess for bowel impaction after BP is less than 150mmHg systolic. Use lidocaine, wait five minutes, check for impaction and GENTLY remove stool if present Assess for other sources of noxious stimulus Pressure ulcers Ingrown toe nails Fractures Acute abdomen conditions Labor and delivery Procedures (ie colonoscopy, cystoscopy) Untreated AD can have long term serious effects: Retinal, subarachnoid, and cerebral hemorrhage Ischemic cerebral vascular accidents (stroke) Seizures Death Neurogenic Bladder Uninhibited bladder Involuntary bladder spasms that completely empty the bladder Caused by lesions on the brain or the subcortical areas Reflex neurogenic bladder Involuntary bladder contraction once bladder signals it is full Infant voiding Caused by SCI above T11 Neurogenic Bladder Autonomous/Areflexic neurogenic bladder Involuntary bladder emptying as an overflow mechanism Bladder does not fully empty Caused by damage to sacral reflex arc (SCI T12 and below) Paralytic Bladder Caused by damage to the efferent or afferent nerves in the reflex arc Motor Paralytic Bladder Have no sensation of need to void Have ability to initiate voiding Have risk for having high volumes Can be caused by childbirth in diabetics, pelvic trauma, and peripheral vascular disease Sensory Paralytic Bladder Have sensation of fullness Have incomplete emptying due to decrease bladder tone and motor function Have high risk for urinary retention Caused by damage at the S2 S4 level 5

6 Intermittent Catheterization New to SIC Size 14 FR to start Style silicone straight tip. If difficulty passing, change to silicone coude Procedure Sterile kit and sterile technique if performed by nursing Sterile catheter and lubricant with clean technique if performed by patient, especially when educating pt in SIC Sterile catheter and lubricant, non sterile gloves, clean technique if performed by caregivers Things to Remember The type of injury will tell you a lot about what the bladder function will be Every injury is not the same Continence is a huge predictor of discharge disposition after rehabilitation Neurogenic bladders can increase the chances of a urinary tract infection Which of the following does NOT typically characterize autonomic Dysreflexia Sweating Nasal congestion Hypotension Bradycardia A patient who has sustained an injury to the conus medullaris will usually have the following bladder symptoms: Hypotonicity, no voiding reflex, overflow dribbling The average adult has a normal bladder capacity of approximately: ml What bladder retraining program would most likely be implemented for a patient with Left hemisphere CVA? Timed voiding schedule Of the following symptoms, which is the most important to assess FIRST in a T5 SCI patient complaining of sudden diaphoresis, nasal congestion, flushing above T5, bradycardia, pounding headache and hypertnesion? A) Examine for bladder distension or fecal impaction B) Administer an analgesic C) Place patient in flat position D) Administer an anti hypertensive medication Ms. Smith is a 35 year old female with an SCI at T11 secondary to a MVA. She scheduled to discharge soon but prior to discharge needs to learn clean intermittent catheterization (CIC) While teaching Ms. Smith to CIC, how far should she be instructed to insert the catheter for the first time? A) one to two inches B) two to three inches C) three to four inches D) four to five inches After becoming proficient at CIC, Ms. Smith starts a urolog to track her outputs. When reviewing the CRRN sees volumes of 552ml, 625ml, 475ml, 625ml and 650ml. She is being cathed every 12 hours by herself, her mother or her aide. What would be the best advice to give? A) Continue with the same bladder program B) Decrease fluids C) Increase fluids D) Increase how often she is cathed 6

7 With a weight of 132lb/60kg, how much fluid should Ms. Smith take in during a 24 hour period to make sure she has an adequate amount of output? A) 1800ml B) 2000ml C) 2400ml D) 3000ml A 65 year old woman complains of chronic urge incontinence because of over active bladder. Which drug is most likely to be the most effective? A) Sertraline (Zoloft) B) Desmopressin C) Duloxetine (Cymbalta) D) Oxybutynin ( Ditropan) A patient with a C5 spinal cord injury is planning to discharge. He had a foley, but has stated he would prefer clean intermittent catheterization (CIC). He is unable to manage cathing himself due to weakness in arms and hands. His wife has verbalized a preference for a Foley catheter. What is the BEST course of action? A) Discharge the patient with a Foley catheter B) Send the patient home with a plan of CIC C) Discuss with the team what the best recommendation is and present it to the patient D) Request a meeting with both the patient and his wife for further discussion References Morrison Media LLC. CRRN Exam Secrets: Your Key to Exam Success. Mometrix Test Preparation. CRRN Exam Questions. 7

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