URINARY ELIMINATION

 Anatomy
o Kidneys/ureters
 Functions
 Maintain composition/volume of body fluids
 Filter/excrete components that are both needed and not needed
 Excrete waste product (urine)
o Nephrons maintain/regulate fluid balance
 Urine from the nephrons empties into the kidneys
o Bladder
 Smooth muscle sac
 Composed of 3 layers of detrusor muscle
o Inner longitudinal layer
o Middle circular layer
o Outer longitudinal layer
 Innervated by the ANS
 Temporary reservoir for urine
 Urethra lets urine pass from the bladder and to the exterior of the body
 Sphincter guards the opening between the urinary bladder and
the urethra
o Urethra
 Male urethra
 Functions in excretory and reproductive systems
 Female urethra
 No part of it is exterior
 Act of urination (micturition, voiding)
o Process of emptying the bladder
 Detrusor muscle contracts and the internal sphincter relaxes
 Urine enters the posterior urethra
 Nerve center for control is located in both the brain and spinal column
 Muscles of perineum and external sphincter relax
 Muscle of abdominal wall contracts slightly
 Diaphragm lowers, micturition occurs
 Micturition is largely involuntary, but control of it can be learned
 Terminology
o Enuresis
 Involuntary passing of urine when control should be established
 Ex. 5 years old
o Nocturnal enuresis
 Bed-wetting, involuntary passing of urine while sleep
 Shouldn’t be considered a problem until after age 6
o Autonomic bladder
 No control, reflex only
 o Polyuria (diuresis)
 Production of abnormally large amounts of urine, several liters more than
normal
o Oliguria
 Low urine input
 Usually less than 500mL a day or 30 mL an hour
o Minimum: 30cc per hour
o Anuria
 Lack of urine production
o Altered urinary elimination
 Urinary frequency
 Frequent voiding of small quantities (50-100mL)
 When you have increased fluid intake, UTI, stress, pregnancy
 Nocturia
 Voiding 2 or more times at night
 Urgency
 Feeling that the person must void
 Dysuria
 Voiding that is painful/difficult
 Urinary incontinence
 Involuntary urination
o This is a symptom, not a disease
 Urinary retention
 When emptying of the bladder is impaired
 Urine accumulates
o Bladder becomes over distended
 Factors associated with this
o Medications
o Enlarged prostate
o Vaginal prolapse
 Factors affecting micturition
o Developmental considerations
 2-3 YO
 Enuresis
 Elderly
 Nocturia
 Increased frequenting
 Urine retention/stasis
 Voluntary control is affected by physical problems
o Food/fluid intake
o Psychological variables
o Activity/muscle ton
o Pathologic conditions
 o Medications
 Diuretics
 Prevent reabsorption of water and certain electrolytes in tubules
 Cholinergic medications
 Stimulate contraction of detrusor muscle
 Produces urination
 Analgesics and tranquilizers
 Suppress CNS
 Diminish effectiveness of neural reflex
 Diseases associated with renal
o Congenital urinary tract abnormalities
o Polycystic kidney disease
o UTI
 Can cause delirium in older patients
o Hypertension
o Diabetes mellitus
o Gout
o Connective tissue disorders
 Medications affecting the color of urine
o Anticoagulants
 Red urine
o Diuretics
 Pale yellow urine
o Pyridium
 Orange/orange-red urine
o Amitriptyline (antidepressant)
 Green or blue-green
o B-complex vitamins
 Green or blue green
o Levodopa
 Brown or black urine
 Physical assessment of urinary function
o Kidneys
 Palpate the kidneys
o Urinary bladder
 Palpate/percuss the bladder
o Urethral orifice
 Inspect for signs of infection, discharge, or odor
o Skin
 Assess color, texture, turgor, and excretion of wastes
o Urine
 Assess for color, odor, clarity, and sediment
 Measuring urine output
 o Have the patient void into a bedpan, urinal, or specimen container
 In bed or bathroom
o Pour urine into the appropriate measuring device
o Place container on a flat surface and read at eye level
o Note the amount of urine voided and record
o Discard in the toilet unless specimen is needed
 Urine specimens
o Routine urinalysis
o Sterile specimens from indwelling catheter
o Specimens for infants/children
 Using the nursing process
o Assessing data about voiding patterns, habits, past history of problems
o Physical examination of the bladder
o Correlation of findings with results of procedures and diagnostic tests
 Assessing a problem with voiding
o Look at its duration, severity, and precipitating factors
o Note the patient’s perception of the problem
o Check the adequacy of the patient’s self-care behaviors
 Nursing diagnoses
o Urinary functioning as the problem
 Incontinence
 Pattern alteration
 Urinary retention
o Urinary functioning as the etiology
 Anxiety
 Caregiver role strain
 Risk for infection
 Planned patient goals
o Produce sufficient quantity of urine
o Empty bladder completely at regular intervals without discomfort
o Provide care for urinary diversion and know when to notify physician
o Develop plan to modify factors contributing to current or future urinary
problems
o Correct unhealthy urinary habits
 Promoting normal urination
o Maintaining normal voiding habits
o Promoting fluid intake
o Strengthening muscle tone
o Assisting with toileting
 Maintaining normal voiding habits
o Schedule
o Urge to void
 o Privacy
o Position
o Hygiene
 Patients at risk for UTIs
o Sexually active women
o Women who use diaphragms for contraception
o Postmenopausal women
o Having an indwelling urinary catheter
o Having diabetes mellitus
o Older adults
 Urinary catheterization
o The introduction of a catheter through the urethra into the urinary bladder via
strict sterile technique
 You need a MD/NP order required to insert catheter
o Reasons for catheterization
 Relieving urinary retention
 Prolonged patient immobilization
 Obtaining a sterile urine specimen when patient is unable to void
voluntarily
 Assisting in healing open sacral or perineal wounds
 In terminal patients
 When turning is too painful
 For improved comfort for end-of-life care
o Types
 Indwelling catheter (retention/Foley)
 Double lumen
 Has a balloon
 Stays inside
 Straight/intermittent
 Single lumen
 Single use
 No balloon
 Coude’ catheter
 Variation of the straight catheter
 More rigid, has a tapered/curved tip
 Used for men with prostatic hypertrophy
o More easily controlled
o Causes less trauma upon insertion
 Bladder/catheter irrigation
o Why it is done
 Performed to maintain/restore the patency of a catheter
 To wash/flush out the bladder
 To apply medication to the bladder lining
 o How it works
 Three-way catheter (triple lumen)
 1 – inflate balloon
 2 – outflow of urine
 3 – irrigation solution
o Procedure
 Done with sterile technique
 Need a MD order
 “3000cc NS bladder irrigation via triple lumen catheter to run
continuously to maintain pale pink tinged urine output”
 “2000cc. NS infused. Urine output 3000cc at end of shift”
o Actual urine output: 1000cc
 Intermittent irrigation
 Determine if the solution needs to stay in the bladder for a certain
amount of time
 Rate varies
 Red/blood  increase until pink
 Clear – 40-60 gtts/min or as ordered
 Medication – MD order
o What to record
 Type/amount of irrigation solution
 Drainage return
 Patient’s comfort level
 Blood clots
 Closed drainage system
o Minimizes the risk of infection
o Hangs on bedrail (not the floor)
 Should always be below the level of the patient’s bladder
o Anti-reflux valve keeps urine in the bag from re-entering the drainage tube and
going back into the bladder
o Observe for kinks/bends in the tubing
 Preventing CAUTIs
o Hand hygiene
o Use catheter as a last resort
o Maintain a sterile closed-drainage system
o Remove as soon as you can
o Routine perineal hygiene
o Empty every 8 hours
 Patient education for urinary diversion
o Explain reason for diversion/rationale for treatment
o Demonstrate effective self-care behaviors
o Describe follow-up care and support resources
 Types of urinary incontinence
 o Transient
 Appears suddenly and lasts 6 months or less
o Mixed
 Urine loss with features of 2 or more types of incontinence
o Overflow
 Overdistention/overflow of bladder
o Functional
 Caused by factors outside the urinary tract
o Reflex
 Emptying of the bladder without sensation of the need to void
o Total
 Continuous, unpredictable loss of urine
o Stress
 Involuntary loss of urine related to an increase in intra-abdominal
pressure
 Factors to consider with use of absorbent products
o Functional disability of the patient
o Type/severity of incontinence
o Sex
o Patient preference
o Failure with previous treatment programs
 Catheters
o Straight/intermittent
 No balloon
o Foley