Friday, March 22, 2019

MANAGE NURSING CARE AT HOME, Ch. 16, Reproductive and Urinary Systems

The organs and functioning units in the reproductive system differ between males and females.  While the basic function of the system, whether male or female, is to produce reproductive cells, gametes; males produce them by way of testes and females via ovaries. 

Regardless of the sex, both reproductive systems require tubes by which the gametes are transported for the union of sperm and eggs (ova) for fertilization and formation of a new organism. 

The male reproductive system includes the penis, vas deferens, testes which produce sperm, and glands which secrete fluids and hormones for the reproductive task. 

The female reproductive system includes the vagina and vaginal canal, fallopian tubes, ovaries which produce ova, uterus, and glands which secrete different hormones and fluids, in a similar fashion necessary for reproduction. 

The reproductive system is often assessed with the urinary system.  In fact, portions of the reproductive system are combined with the urinary system.  This is termed the urogenital system. 

Numerous disorders can occur in the reproductive system.  They are often related to cancer, such as ovarian, uterine, testicular, for example.  Other problems result in infection or excessive growth of glands such as the prostate, as exhibited with prostatitis and benign prostatic hyperplasia (BPH), respectively, in males, causing difficulties in urination, for example.  Females often exhibit problems and disorders with menstruation when abnormal and excessive uterine bleeding, lack of menstruation, (amenorrhea) or painful menstruation (dysmenorrhea).

Many disorders and problems affecting the reproductive system require surgical intervention.  Once the dysfunctional organ is excised (removed), home care considerations then relate to post-surgical care, which includes assessing for signs and symptoms of infection, promoting healing, and allowing time to return to normal function. 

Reproduction is the process by which new life is formed.  While the method is very different for plants versus animals, the outcome is the same.  The purpose of reproduction is to produce new life to ensure the species not only continues, but thrives.  Genetic material is passed down from generation to generation.  However, duplication is not the sole purpose.  Replication of the species’ best properties are passed down and changes to the genetic material are made over time to propagate and enhance the entities, resulting in increased chances of survival as well as a stronger, and sometimes more advanced organism.

In humans, the goal of reproduction is to produce children who are biological descendants, as well cultural, traditional, and familial offspring.  This is accomplished by a union of male and female genetic material brought together via sexual reproduction.  To complete this task, although the two sexes have different anatomy and function independently, they work together (synergistically) to obtain one outcome: fertilization of reproductive cells (gametes) for formation of a new organism. 

Gametes include sperm in males and eggs (ova) in females.  Both sexes have structures (gonads) that produce gametes, with tubes and ducts for gamete transportation, and glands which secrete substances to support and enhance survival of the gametes and fertilization.

In males, the gonads that continually produce sperm throughout a male’s lifetime are the testes.  Testes are dual oval-shaped glands which also have cells producing fluids to nourish sperm and others which produce the hormone testosterone.  The testes are held in place by the scrotum which functions to adjust the temperature within the testes necessary for sperm viability and development.  Muscles in this tissue contract with decreased temperature to bring these organs closer to the body to provide warmth.  In contrast, these muscles also relax to lower them from the pelvis for cooling. 

Mature sperm are transported to and stored by the ductus deferens (also called the vas deferens) which also functions to force sperm to a portion of the urethra (the prostatic urethra) during ejaculation via the penis.  Other accessory sex glands produce and secrete substances that form semen, the liquid portion of ejaculated fluid that does not include sperm.  Semen provides a substance for sperm transportation and motility as well as neutralizing fluids to promote their viability to increase chances of fertilization.

In females, the gonads that produce eggs (“ova”: singular is “ovum”) are the ovaries.  Like male testes, these are dual almond-shaped glands but contained within the body; they store and mature ova prior to their release during ovulation.  Historically it was believed that ova are not constantly produced and that the number present at birth remains static until death.  This is the opposite of sperm production.  However, some evidence suggests that this may not be the case but has yet to be determined conclusively.  

The ovaries also secrete the hormones estrogen and progesterone to assist in the maturation process of an ovum along with other hormones, as well as prepare the female body for implantation if fertilization should occur.  Once an ovum has matured and is released from an ovary, it is transported via the uterine (or fallopian) tubes, where fertilization by sperm usually occurs, to the uterus.  Regardless of whether the ovum was fertilized, the fallopian tubes provides the route for the egg to reach the uterus. 

If the ovum is fertilized, it will implant itself in the uterine wall for growth, maturation, and development into an embryo and later, a fetus.  If unfertilized, it will eventually be discarded with uterine tissues during menstruation.  The vagina is basically a structural passage that allows transport into and out of the uterus.  Sperm moves from the penis into the vagina during intercourse.  Sperm then proceeds into the uterus into the fallopian tubes to fertilize ova.  If the ovum is fertilized, during birth it serves as part of the birth canal.  If fertilization does not take place, the vagina functions to eliminate and evacuate uterine blood and tissues during menstruation.  

In addition to the overview of the structure and function of the male and female reproductive system presented here, there are other structures which have not been described.  In addition, disease process and illnesses are also not addressed, as many interventions are dictated around medications or surgical procedures. Lastly, although this system is often addressed and assessed in conjunction with the urinary system; nevertheless, they are two very distinct and separate systems. 

In this section, urinary disorders will be addressed. 

While the digestive system’s large colon eliminates solid waste, the urinary system functions in a similar capacity in the removal of liquid waste via the kidneys.  By using a complex method of filtration, various tubes throughout the system capture and retain needed bodily fluid, minerals, and electrolytes, and the remaining fluid and non-essential substances are stored in the bladder to be later excreted as urine.  In addition, the system helps to regulate calcium and the acid-base (pH) balance of the body. 

The urinary system is comprised of the kidneys (to regulate the amount and composition of the blood by producing urine), ureters (to move urine from the kidneys), bladder (to hold and store urine received from the ureters), and urethra (to release urine from the bladder for elimination outside the body).   While the functional elements of the urinary system do not differ between males and females, the length of the urethra does.  Therefore, females are more prone to urinary tract infections. 

The kidneys are the main organ of this system and are comprised of small units (nephrons) that filter the body’s blood.  Besides maintaining fluid balance by eliminating excess water, they perform many other functions.  They regulate the composition of fluid by removing or retaining various electrolytes such as hydrogen, sodium, potassium, chlorine, and regulate the body’s pH within a small range of 7.37 to 7.43.  Too much retained hydrogen results in metabolic acidosis; too little results in metabolic alkalosis. 

By regulating the amount of water that is retained in the body, the kidneys assist in the regulation of blood pressure.  This system also produces erythropoietin when the body’s blood oxygen supply is decreased.  This hormone then prompts the bone marrow to produce red blood cells.  Also, they synthesize vitamin D.

Disorders of the renal (kidney) system can be acute or chronic.  The severity dictates whether measures are required to provide or enhance elimination of urine, as well as provide filtering of the blood.  Acute renal failure can resolve, and normal function may resume.  Chronic renal failure is irreversible and may require dialysis to remove toxins and fluid that the kidneys are no longer able to remove via filtration. 

Hyperplasia (abnormal growth) of the prostate gland in males can restrict urine to pass, causing a feeling of urgency, a slow stream, and incomplete evacuation of the bladder.  Medication often enhances flow but at times surgical intervention is necessary.  Other methods of urinary elimination may take the form of catheters or surgical urinary diversions.

Some of the various urinary system conditions and care considerations that may be experienced in the home-care setting appear below.

Chronic Renal (Kidney) Disease: is caused by a gradual and prolonged destruction of nephrons, which results in the inability to filter enough fluid and waste from the blood.  This disease often results from infection, diabetes, or high blood pressure.  As the amount of functioning nephrons declines, filtering the blood of toxins and waste decreases as well.  At the point at which most nephrons no longer function and the substances in the blood that are normally filtered and excreted by the kidneys remain, uremia results, a toxic situation causing harmful conditions in many other bodily systems.   At this point, because the kidneys no longer are functioning sufficiently, dialysis is usually necessary to remove excess fluid and toxins from the blood.  

Excess fluid in the blood (hypervolemia) can contribute to cardiac problems such as increases in blood pressure and pulses or lead to congestive heart failure.  Respiratory complications are evidenced by crackles (a type of adventitious lung sounds) or life-threatening pulmonary edema.  Generalized edema is noted in feet, ankles and puffiness around the eyes.  However, the opposite is also possible, and too much water is lost by lack of reabsorption (hypovolemia).  This can lead to dry and scaling skin, hair, and nails, and lack of skin turgor (firmness). 

Waste build-up in the blood causes retention of potassium (hyperkalemia) which can cause cardiac arrhythmias, malaise, muscle cramping, paralysis, and even cardiac arrest.  Increases in phosphate (hyperphosphatemia) caused by decreased excretion can also lead to cardiovascular risks. 

Anemia results from lack of red blood cell production when erythropoietin is no longer synthesized.  Weak bones (osteomalacia) occurs due to lack of calcium (hypocalcemia) caused by a decrease in the synthesis of vitamin D by the kidneys.  

Azotemia results when there is an accumulation of nitrogen and urea which are the products of protein metabolism.  As wastes build up, the GI system is also affected, presenting as nausea, vomiting, anorexia, and abdominal pain.  Neurological symptoms appear as confusion, altered levels of consciousness and mentation. 

Acute Renal Failure: is the sudden loss of kidney function.  It may result from the obstruction of blood or from trauma resulting in decreased blood flow to the kidneys, damage to the filtering structures within the kidneys due to toxins or infection, or obstruction of urine outflow.  Often this condition is reversible with the return of most, if not all, kidney function.  Primary treatment is the reversal of the failure’s cause.

Regardless of the cause, the acute disease progression can result in the same or similar symptoms as the chronic disease.  The severity, length, and course of the illness will depend on the damage incurred as well as on the underlying cause.  Typically, however, the healing and recovery process will follow three paths or phases.  The first phase is the oliguric phase, and during this time there is a decrease in urine secretion.  The diuretic phase is the opposite.  During this second phase, urine output is greatly increased.  The last phase is the recovery phase.  It is in this phase that normal function gradually returns, with the elimination of wastes and fluid.  However, if the underlying cause of the acute condition is not reversed, chronic renal disease could follow.

Care Considerations for Chronic Renal Disease and Acute Renal Failure:
1)  Primarily dietary changes are required for both diseases.  However, the acute illness should be temporary, and care involves supportive actions.  Conversely, the chronic disease usually increases in severity with the potential of requiring artificial blood filtering (dialysis).
2)  Depending on the stage of the disease, patients should consume low-protein diets to decrease protein metabolism and the byproducts that the kidneys can’t excrete. 
3)  Electrolyte balance is necessary because the kidneys are no longer able to remove these from the blood, and excesses of some can be damaging to the body, even deadly.  The amounts of potassium and phosphorus require monitoring, and foods that are plentiful in these substances should be avoided.  Some medications are available to bind electrolytes to decrease their availability in the blood and make elimination easier.
4)  Fluid intake should be restricted as in later of stages of the disease, oliguria (decreased urination) or anuria (inability to urinate) result.  Restricting fluid prevents fluid overload, and this can decrease risks for high blood pressure, edema, and pulmonary overload.
5)  Monitor and record fluid intake and output.  Recording both provides indication of fluid retention in the body.  Daily weights can also provide insight with respect to excess fluid in the body.
6)  Restrict sodium to decrease water retention. 
7)  Assess for signs and symptoms of uremia caused by nitrogen substances that are retained in the body.  Symptoms include dizziness, nausea, vomiting, coma, convulsions, hypertension, hard rapid pulse, dry skin, oliguria or anuria, odor of urine on the breath or in perspirations.  Treatment often requires dialysis
8)  Due to weakness from toxin build-up or increased fluid retention, mobility could be an issue.  Perform range of motion exercise and position changes.  Safety measures include neurological assessments for dizziness or confusion (altered mentation) as well as muscle fatigue, cramping, and weakness from excess potassium.
9)  Administer medications as ordered.  Numerous drugs assist in the conditions associated with kidney disease.  Anti-hypertensives are prescribed to lower blood pressure.  Diuretics are taken to promote urination and decrease fluid retention when the ability to void is present.  Anti-emetics are used to decrease nausea, vomiting, and gastrointestinal irritation.  Laxatives and stool softeners are used to promote bowel elimination which can be a secondary problem due to lack of fluids, limited mobility, and dietary changes.  Iron supplements may be used to combat anemia.  Synthetic erythropoietin may be injected to promote formation of red blood cells.  If this is ineffectual, blood transfusions may be required.  Anti-pruritics are administered to relieve itching (pruritus) that often results from dry skin.  Electrolyte binding medications may be given to decrease serum phosphate or potassium levels.  These medications will not provide a cure to the disease but can relieve adverse symptoms associated with it.
10)  During the end stage of the disease, some form of dialysis is most often required.

Dialysis: is required during the most severe and final stage of kidney disease (end-stage renal disease).  Dialysis is performed to remove fluid and toxins that the kidneys would normal filter, resorb, and excrete from the body.  The two most common types of dialysis are hemodialysis and peritoneal dialysis.  Whichever method is used, this treatment will continue throughout the life of the patient or until a kidney transplant is performed.

Hemodialysis (HD) filters the blood and is accomplished by a machine that removes “dirty” blood from the body, filters it via a semi-permeable membrane to eliminate toxic materials and electrolytes as well as to maintain proper fluid levels and acid-base balances.  “Clean” blood is then returned to the body.  This type of dialysis requires a surgically made connection or passage (fistula) between a vein and an artery, usually created in the upper extremity, called an arteriovenous (AV) fistula.  Often dialysis is performed at an outside, dedicated dialysis facility three times a week, with each session lasting roughly 4 hours. 

Peritoneal dialysis (PD), although providing the same outcome, uses the peritoneal cavity as the filtering membrane.  A permanent catheter is implanted into the abdomen to instill a warm, sterile dialyzing chemical solution into the peritoneal cavity.  The solution remains for a prescribed amount of time and it then removed.  This process could take place overnight or throughout the day at regular intervals.   The advantages to this type of dialysis are the ability to perform the action individually, and not having to rely on outside intervention or long-lasting appointments.  However, infection at the catheter site or peritonitis can be complications.

Care Considerations for Hemodialysis and Peritoneal Dialysis:
1)  Hemodialysis (HD) uses a surgically fashioned AV fistula or AV graft.  This is created under the skin with no outside route that can lead to infection.  However, during the dialysis process, needles are inserted, and strict aseptic technique is required to prevent infection.
2)  The HD fistula and the extremity in which it is placed require caution, care, and watchfulness to protect that extremity and fistula.  That fistula or graft provides life to the patient.  Blood pressure readings, tight clothing, injury, and blood sampling should not be performed on that arm. 
3)  Peritoneal dialysis (PD) requires strict aseptic technique to perform the procedure.  In addition, dexterity and eyesight is necessary to perform the connections of the dialysis solution to the catheter while maintaining sterility.
4)  The patient using PD needs to adjust his lifestyle to coincide with the dialysis process.  This includes adjusting medication scheduling to coincide with the PD process, especially if it is performed at different intervals on different days, as well as allowing enough time for the instilled solution to remain to complete filtration.  After the solution is instilled, a bloating, full, uncomfortable feeling can be exhibited.  However, the solution must not be prematurely drained.  If the solution is instilled at night time during sleep, changes to the bedroom and sleeping routines may be required.
5)  Proper care to the PD catheter is required.  The site should be assessed for inflammation and infection daily.  If infection is suspected, obtain medical assistance.    
6)  Assess for signs and symptoms of peritonitis with PD.  This can potentially be a life-threatening condition.  Symptoms include chill, fever, fast heart rate (tachycardia), abdominal pain or distention, respiratory difficulty due to decreased effort related to the pain, vomiting, and low blood pressure (hypotension).  Seek medical assistance immediately.

Urinary Diversions: are surgical procedures creating reservoirs for holding urine.  In these procedures, the kidneys function within normal limits.  However, the elimination of urine does not occur due to trauma or cancer of the bladder or urethra, for example.  Urine is merely rerouted and diverted rather than proceeding to the bladder for storage and eventual voiding via the urethra to the outside of the body via the abdomen.    There are two types of urinary diversions:  continent diversions and incontinent diversions.  Both types require the patient to be sufficiently dexterous to either perform a sterile catheterization or change outside appliances. 

Continent diversions are internal pouches created from a portion of the large intestine.  A stoma is created with a closure piece that is like a valve that can be opened or closed at will.  This eliminates urine leakage.  The reservoir is internal but self-catheterization is required to empty urine from the pouch, and this is required approximately four to six times per day.  In addition, because the pouch is created from a segment of the large intestine, which produces mucus to aid in stool elimination, the reservoir requires irrigation to decrease potential for blockage from the mucus.  However, there are no outside bags to collect urine, no leakage, and clothes can be protected with the use of a small piece of gauze to trap mucus.  Sterile technique is required during the procedure.

Incontinent diversions are like colostomies which reroute stool from the colon to an outside collection appliance.  The difference is that urine is collected.   With this type of diversion, there is an opening directly to the abdominal wall.  Appliances are always required, and the bags must be emptied frequently.  However, there is no sterile technique required and no irrigation.  The bag is held in place, again similar to colostomies, by adhesives.  But these can be irritating to the body. 

Care Considerations for Continent Urinary Diversions:
1)  Sterile technique is required when emptying the pouch during catheterization.  It is also essential to clean the site before and after the procedure.  Before catheterizing (or intubation), clean the stoma in outward circular motions with a prescribed cleansing agent (such as providone-iodine).  When done emptying the pouch, again clean with gauze and liquid soap, rinse, and pat dry.  Care to the stoma and nearby (peristomal) skin as well as sterile technique is essential to maintenance of the device and to minimize risk of infection.
2)  Before inserting catheter, lubricate with a water-soluble lubricant.  Using petroleum-based products increases risk of infection.  Lubrication also decreases damage to the valve when inserting the catheter.  Gently insert the catheter using a rolling motion in minimize damage, and continue until urine flows.  Taking deep breaths during insertion or changing positions can aid in inserting the catheter if resistance is felt.
3)  During irrigation, after emptying the pouch at regular intervals, irrigate and instill sterile normal saline.  The amount and time frames when this is required should be prescribed.  Irrigation is required to prevent blockage that can occur due to the mucus produced by the large intestines.  The saline will drain with gravity.
4)  Before the catheter is removed from the valve, patient should cough a few times.  This will help expel residual urine and/or normal saline from the pouch. 
5)  After intubation catheter use, clean as recommended by manufacturer or physician, or discard if single-use only.  If reusable, be sure to rinse well to clear all mucus.
6)  Ensure a catheter is always available and ready to use.  Keep track of intubations to ensure the reservoir does not become too full.  In time the size of the pouch will increase.  Damage to the reservoir or urine leakage could occur with too much urine volume. 
7)  Body image disturbances are common, especially after initial creation.  Provide encouragement, supportive communication, and patience.  Help with tracking intubation times and provide gentle reminders if necessary.  Allow patient to express difficulties and vent frustrations but direct him to positive outcomes.

Care Considerations for Incontinent Urinary Diversions:
1)  When applying new ring and appliance, ensure that measurements of the stoma compared to the outside appliance ring and pouch are within a small margin for proper placement around the stoma.  This is usually 1/16 to 1/8 of an inch.  If the ring is too large, leakage may happen.  If it is too small, damage to the stoma could occur. 
2)  After emptying the pouch, cleanse the stoma and area with soap and water.  Pat the skin dry to decrease possible irritation.  Apply skin preparations, if so advised, to help adhere appliance and provide protective barrier to the skin.  Then apply ring and appliance and hold in place to ensure a solid seal.
3)  At night, the pouch can be connected to a drainage bag for continuous removal via gravity.  This helps to eliminate leakage or build-up of urine that can create difficulties during sleep when volume is not attended to.
4)  Body image disturbances are common especially after initial creation.  Provide encouragement, supportive communication, and patience.  Offer to assist with measuring appliance and skin care.  Allow patient to express difficulties and vent frustrations but direct him to positive outcomes.

Urinary Catheterization:  is performed to allow urine to flow from the bladder for elimination outside the body.  This may be required when spinal cord injuries prevent normal voiding due to loss of function from spinal nerve damage.  Often fully incontinent patients are catheterized to prevent spontaneous voiding which could cause damage to skin due to moisture and the acidic nature of urine.  Other times, it is done to provide a “normal” lifestyle.  Besides providing a means to eliminate and collect urine, sterile urine sampling can be obtained for diagnostic testing related to urinary tract infections, for example.  There are many types of catheters that can be used.  These include indwelling bladder catheters, intermittent catheterization, and condom catheters for males.

Indwelling catheters are often used in hospital and nursing home settings due to incontinence but are also used when obstruction prevents normal urination.  These catheters are inserted into the urethra up to the bladder.  After placement is established by the flow of urine, sterile normal saline is inserted into a balloon to hold the device in place.  Urine is then eliminated via gravity into a collection bag.  Risk for infection can be high during placement as well as during the time the catheter is in place.  In some cases, kidney disease can result due to upward moving infections that traveled along the catheter to the bladder eventually affecting the kidneys. 

Intermittent catheters are preferred to indwelling catheters, which cause increased risk of infection to the urinary tract. However, catheterization is required often, and this increases the infection risk during each insertion.  This form of catheterization is often necessary for paraplegics and individuals with spinal cord injuries.  Although there is no obstruction of the urethra, signals from the brain are blocked and prevent normal voiding.

A condom catheter is specific to incontinent males.  As the name suggests, a condom-like apparatus is place over the penis and urine flows from the condom via tubing to a collection bag that is placed on the leg.   There is virtually no loss of mobility.  Although risk for infection always exists, there is no invasive procedure to the sterile bladder cavity.  The bag is emptied when approximately half full.  There is, unfortunately, no similar solution for females.

Care Considerations for Urinary Catheterization:
1)  All catheters are vulnerable to urinary tract infections that may result during placement or dwell time.  Strict sterile technique is required for placement, without exception, as the urinary system is a sterile one and is easily contaminated.  Infections in the bladder, for example, can progress upward to the kidneys and cause irreparable harm to kidney function.  In addition, extreme results can result in septicemia which is an infection that spreads to the blood. 
2)  Whether an intermittent or indwelling catheter is placed, consideration is required concerning the sex of the patient.  The male patient’s urethra is very long and typically extends approximately 12 to 13 inches before reaching the bladder.  In contrast, the female urethra is only about 5 inches in length.  Continue to slowly progress the catheter until urine is expelled, using sterile technique during the entire time.  Stopping and restarting the procedure prolongs discomfort and increases the risk for infection.
3)  The patient will normally experience pressure and discomfort during the process if sensations are recognized.  In addition, often the bladder is distended which causes discomfort itself.  Deep breaths will help advance the catheter.  Ensure sufficient lubrication is provided on the catheter before insertion.  Relief will be felt immediately upon entering the bladder.
4)  If the patient is an uncircumcised male, the penis foreskin must be pulled back.  Ensure that the foreskin is replaced and returned to the original position prior to the catheterization. Retracted foreskin can cause damage due to potential lack of blood supply to the organ.
5)  Once the catheter enters the bladder, urine will flow.  Normal voiding occurs when the bladder contains approximately 250mL.  The maximum immediate outflow of urine after catheterization should be no more than 1000mL.  Exceeding this amount can cause detrimental fluid shifts within the body.
6)  If an indwelling catheter is placed, remove it as soon as possible to decrease risk for infection.


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

Web site:

Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin

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