Urinary Elimination

HNI 378

Department of Undergraduate Studies

Kidneys
Nephron

Roles of Kidneys

Filter blood
Compose urine
Produce erythropoetin
Produce renin
Ca+ and phosphate regulation

Ureters
Tubular structures with peristaltic
waves
Extend to urinary bladder
Urine here is sterile
Obstruction of ureter (kidney stone)
leads to pain often referred to as
renal colic. Once stone has passed
into bladder pain is relieved urine
is strained for stone.

Bladder
Hollow, distensible, muscular organ
(detrusor)
Urine reservoir
Located in front of the uterus and
vagina in females. In males, located
in front of the rectum and above the
prostate gland.
Normally holds between 600ml1000ml of urine

Urethra
Carries urine from bladder out of the
body via urethral meatus
Females: 1.5 2.5 long, located
between labia minora; above vagina
Males: 8 long; located at distal end
of penis

Ureters and Bladder

Act of Urination
Bladder wall stretches, sensory
impulses are sent to the micturition
center, internal urethral sphincter
relaxes (urine enters urethra).
Impulses sent to the brain person is
conscious of the need to urinate.
Impulses are ignored or responded to
voluntarily if choose to ignore external
urinary sphincters contracted and
micturition reflex is inhibited.
When ready to void external sphincter

Health Promotion for normal

urinary elimination
Assume normal position (women vs
men)
Promote relaxation - running water,
warm water over the perineum
Maintain adequate fluid intake (2L)
and voiding routines.
Encourage patient to wait until urine
flow stops or attempt to void again
can improve bladder emptying
Good perineal hygiene

Urinary Retention
Incomplete emptying of the bladder
150-250 ml or 25% of total bladder capacity
remains in bladder after voiding. Severe
retention 2000mls
Etiology
Urethral obstruction (enlarged prostate gland
or urethral edema after childbirth or surgery)
Hysterectomy (Uterus supports bladder in the
upright position)
Alterations in motor or sensory innervation
After removal of indwelling catheter
Medication (Antihistamines & Anticholinergics
block contraction of detrusor muscle

Nursing Assessment for

Urinary Retention
Bladder distended upon palpation
Absence of urine output, or voided
small frequent amounts (retention
overflow)
Discomfort (possibly)

Interventions - Urinary
retention
Post-void catheterization or bladder
ultrasound
Time-voiding
Relax pelvic floor muscles feet on floor
Stimulate bladder contraction
Caffeine, hydration, pour water over
perineum, listen to water running

Double Voiding
Individual voids, rest/relax 3 -5 min; attempt
to void again

Urinary Incontinence
The involuntary leakage of urine that is
sufficient to be a problem.
Types:
Functional

inability of a normally continent person to reach

the bathroom in time to avoid unintentional loss of urine

Overflow
Reflexinvoluntary loss of urine, occurring at somewhat
predictable intervals when a specific bladder volume is
reached overcoming sphincter control

Stress:

increased abdominal pressure causes involuntary loss

of small amounts of urine

Urgerandom involuntary passage of urine after a strong

urge to void

Functional Incontinence
Inability to manage toileting
independently
Cognitive limitations
Physical limitations getting to toilet,
managing clothing
Environmental limitations wheelchair
access to bathroom, no bathroom on first
floor of home

Interventions
Modification of environment, clothing
Supervised/assisted toileting

Overflow Incontinence
Bladder is full
Frequently incontinent of small amounts
of urine (25-60 mL)
Post-void residual volume of urine is >
300-400ml

Etiology
Bladder outlet obstruction- (BPH)
Surgery/ anesthesia
Neurogenic bladder loss of innervation
DM or spina bifida

Overflow Incontinence
Interventions for
individuals with BPH

Catheterization
Alpha-adrenergic blocker to decrease
outlet pressure
tamsulosin (Flomax)
terazosin (Hytrin)*
doxazosin (Cardura)*
*nonslective alpha 1a act on receptors in blood
vessels - vasodilation and lower BP (orthostatic
hypotension)

Reflex Incontinence
Involuntary loss of urine when a
specific bladder volume is
reached.
Neurological impairment
Above level of micturition center (spinal cord
injury)

Interventions
Intermittent self-catheterization
Superpubic tube

Stress Incontinence
Leakage of small amount of urine with
sneeze, cough, jumping. Usually small
amounts of urine.

Etiology
Relaxed pelvic floor muscles
Childbirth
Post-menopause sphincters relax, urethra
and bladder become less elastic
Prostate surgery for benign prostatic
hypertrophy (BPH) or prostate cancer
Increased intradominal pressure. Obesity.

Stress Incontinence Interventions

Strengthen pelvic floor muscles
Kegel exercises

Weight loss if obese

Surgical interventions
Topical estrogen products
Absorbent products

Patient Education Diagrams

Pelvic floor muscles

Urge Incontinence
Overactive bladder (OAB): uncontrolled
contraction of the bladder muscles
resulting in 4 major symptoms (urinary
urgency, urinary frequency (>8Xs/24
hours), nocturia and urge incontinence.

Large volume of urine

Etiology
Most prevalent in elderly Reported in
42% men and 31% of women over the
age of 75
Urine leakage is unpredictable and

Urge Incontinence Interventions

Behavioral therapy - Bladder retraining
Time intervals between urges to void toilet at
that time
Increase interval by 15 min each week
To control the urge to void relaxation,
distraction and or contraction of pelvic floor
muscles
Timing fluid intake appropriately
Pelvic floor muscle strengthening Kegel
Reduce bladder irritants (smoking; caffeine)
Drug therapy - Anticholinergic medication
approved for OAB
Oxybutynin (Ditropan); Tolterodine (Detrol); Solifenacin

Urinary tract infections

ETIOLOGY
Residual urine in bladder
Catheterization 80% of UTIs; most common
HAI - CAUTIs
Fecal incontinence or poor perineal hygiene
Ecoli most common pathogen

MANIFESTATIONS
Symptoms: burning with urination ; urine is
cloudy, malodorous, not usually febrile unless
septic, urgency, incontinence, frequency,
hematuria
Elderly confusion or change in mental status

Prevention of UTIs

Good perineal hygiene

Adequate fluid intake - (high acidity)
Voiding after intercourse
Not using excessive soaps or taking
bubble baths
Wearing cotton underwear
Indwelling catheters
See the box 45-10 (p. 1063) for tips on
preventing infections

Urinary tract infections

Manifestations
Urinalysis (UA)
Nitrates produced by bacteria
White blood cells (WBCs)
Bacteria

Culture and sensitivity

Predominant organism If multiple
organisms are found in small amounts
indicate contamination of specimen

Interventions - UTI
Antibiotics
Adequate fluid intake
Repeat UTIs
Nitrofurantoin (Macrobid, Macordantin)
Ongoing use
Decreases bacteria count in residual urine

Urinary Diversions (from

bladder)
Urostomy ileal
conduit - Continent
urinary reservoir
created from a
distal portion of the
ileum and prox
portion of the
colon. Sits under
abd wall, ileal
segment is brought
through wall and
acts as a stoma.

Assessment of Urine

I and O
Color
Clarity
odor

Urine Testing Types of

Specimens
Urinalysis ph (4.6-8) protein none-trace, glucose-none, ketonesnone, blood-none, specific gravity
(1.005-1.030)
Urine Culture
Midstream (clean catch)
Sterile: (obtained from catheter)

Timed: 24 hour urine

Serum tests: BUN, creatinine

Diagnostic Procedures for

Urinary System
What are some of the diagnostic
procedures for the urinary system?
Nursing considerations?

Catheterization

Types: intermittent vs. indwelling

Insertion: Sterile procedure, clean urethral opening,
advance lubricated catheter until urine return, then
advance another 2 inches and inflate balloon, gently pull
back until resistance is felt and secure to upper thigh.
Nursing care:
Frequent perineal care q8h
Clean 2 of catheter
Ensure drainage bag remains below the level of the clients
waist
Handwashing/Strict aseptic technique used in hospitals.
Maintain closed system.
Spigot clamped and in protective pouch

REMOVE AS SOON CLINICALLY NECESSARY

Catheters