Short essays by Douglas Winslow Cooper, Ph.D., the author of TING AND I: A Memoir of Love, Courage and Devotion, published in September 2011 by Outskirts Press (Parker, CO, USA), available from outskirtspress.com/tingandi, Barnes and Noble [bn.com], and Amazon [amazon.com], in paperback or ebook formats. Please visit us at tingandi.com for more information.
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
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
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
The ovaries also secrete the hormones estrogen and
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
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
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
Hyperplasia (abnormal growth) of the prostate gland in
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
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
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
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
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.
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
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.
(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
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.
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.
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.
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.
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
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
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
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
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.
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.
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.
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.
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
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
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.
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.