URINARY

ELIMINATION
Anthony P. Olalia Jr.
 PRETEST
• On anatomy physiology
BRIEF DISCUSSION OF ANATOMY AND
PHYSIOLOGY
• The function of the urinary system is to
• remove waste products from the blood and
eliminate them from the body.
Other functions of the urinary system include
- regulation of the volume of body fluids,
- the balance of pH and the electrolyte
composition of these fluids.
 ANATOMY AND PHYSIOLOGY
• Kidneys
The kidneys are located in the back of the upper abdomen
and are protected by the lower ribs and rib cartilage of the
back. The kidneys are involved with a number of bodily
functions which include:
• The filtering and excretion of unwanted waste products
such as urea from the body.
• The maintenance of water balance.
• the regulation of the acid-base balance of body fluids.
• the production of renin, which is important in the
regulation of blood pressure.
• The production of the hormone erythropoieten, which
stimulates the production of red blood cells.
• Ureters
The ureters are two slender tubes that run
from the sides of the kidneys to the bladder.
Their function is to transport urine from the
kidneys to the bladder.
• Bladder
The bladder is a muscular organ and serves as
a reservoir for urine. Located just behind the
pubic bone, it can extend well up into the
abdominal cavity when full. Near the outlet of
the bladder is a small muscle called the
internal sphincter, which contract involuntarily
to prevent the emptying of the bladder.
• Urethra
The urethra is a tube that extends from the
bladder to the outside world. It is through this
tube that urine is eliminated from the body.
 URINATION
• Micturation, voiding and urination – process
of emptying the blooder
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• AMOUNT IN 24 HOURS (ADULTS)
NORMAL
- General rule (1 ml/kg/hour) x 24hours – ask them to
compute their normal urine output
- Hospital setting – ideally not less than 30 ml/hr
- In 24 hours Adults = 1,200-1,500 ml
ABNORMAL
- Large difference (under or more than) of output with intake -
Urinary output normally is approximately equal to fluid intake
- Output less than 30 ml per hour or 720 in 24 hours –
indicative of poor blood flow to kidneys and poor kidney
function
- Output more than 2500 in 24 hours
CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• AMOUNT IN 24 HOURS (ADULTS)
NURSING CONSIDERATION
- Report abnormal output
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• COLOR, CLARITY
NORMAL
• Straw, amber transparent
ABNORMAL
• Dark amber – concentrated urine (darker), indicates dehydration
or supports diagnosis of hypovelemia
• Cloudy – due to white blood cells, bacteria, or contaminants such
as prostatic fluid, sperm or vaginal drainage
• Mucous plugs, vscid, thick – supports diagnosis of infection
• Dark orange – may be effects of drugs (e.g. rifampicin – orange
red, vitamin b supplements) other example (aldomet/methyldopa
for hypertension – black urine)
• Red/dark brown – due to blood in urine = gross hematuria (may be
due to menstruation – normal, or other conditions – infection or
trauma to kidneys or bladder)
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• ODOR
NORMAL
• Faint aromatic
Abnormal
• Offensive urine
- Effects of food – asparagus, onions, garlic
- Infection – fowl smelling
- Diabetes – sweet smelling urine (acetone smell)
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• STERILITY
NORMAL
• No micro organisms present r/t sterile kidneys and
bladder
ABNORMAL
• Microorganism present
- Infection in the urinary tract
- Improper collection of urine specimen
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• pH
NORMAL
• 4.5-8
ABNORMAL
• Over 8 – may indicate
- infection (bacteria in urine spilts urea into ammonia and other alkaline
waste product
- state of alkalosis (system is alkaline may be secondary to hyperventilation)d
- diets high in fruits and vegetables
• Under 4.5 – found in
- Starvation and dehydration and diarrhea
- State of acidosis – Hypoventilation
- Uncontrolled diabetes
- Diet = acid ash (cranberry juice), high protein diet
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• SPECIFIC GRAVITY
NORMAL
• 1.010 – 1.025
ABNORMAL
• Over 1.025 = concentrated
• Below 1.010 = diluted
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• SPECIFIC GRAVITY
NORMAL
• 1.010 – 1.025
ABNORMAL
• Over 1.025 = concentrated, patient is dehydrated
• Below 1.010 = diluted, inability to concentrate urine
= kidney diseases or diabetes insipidus (absence of
ADH)
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• GLUCOSE
NORMAL
• Not present
ABNORMAL
• Present (glucosuria)
• May indicate indiagnosed or uncontrolled diabetes
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• KETONE BODIES (acetone) – breakdown of fatty
acids
NORMAL
• Not present
ABNORMAL
• Present (Ketonuria) – may occur in individuals with
- Diabetes
- Starvation
- High fat low carbohydrate diet
 CHARACTERISTICS OF A NORMAL AND
ABNORMAL URINE
• BLOOD
NORMAL
• Not present
ABNORMAL
• Present (hematuria) – may be due to infection,
trauma…
• Gross – bright red urine
• Occult- microscopic
 FACTORS AFFECTING VOIDING
INFANTS (0-1)
• Urine output = 250-500 ml per day
• Frequency = as much as 20 times a day
• Color = colorless
• Odor = odorless
• Specific gravity = 1.008
• Have immature kidneys = less ability of concentrating
urine
• Infants has no urinary control until 2-5 years of age =
enuresis (e.g. bedwetting = nocturnal enuresis)
 FACTORS AFFECTING VOIDING
PRESCHOOLERS (3-5)
• Toileting – right of passage from toddlerhood (2-3) –
preschoolerhood. Symbol of “bigness”
• How do you know the kid is ready
1. Nighttime bowel control
2. Daytime bowel control
3. Daytime bladder control
4. Nightime bladder control
Enuresis (involuntary passage of urine) = control should
be established at about 5 years of age
1. child able to walk and sit
 FACTORS AFFECTING VOIDING
School-Age children (6-12)
• Elimination system = mature
• Frequency = 5-10 times a day
• Bedwetting = should be inexistent
• Bedwetting should not be considered a problem
until after 6
- Primary – child has never achieved nighttime
urinary control
- Secondary - child has achieved nighttime control
for 6 consecutive months
 FACTORS AFFECTING VOIDING
ELDERS
• Kidney function diminish with age but usually
not significantly below normal levels unless
adisease process intervenes masquarade
 ALTERED URINE PRODUCTION
• Peoples pattern of urination are highly
individual
• Most people void about 5-6 times a day
 ALTERED URINE PRODUCTION
• POLYURIA/diuresis
- Refers to the production of abnormally large
amounts of urine by the kidneys
Can follow
- polydipsia – excessive fluid intake
- Diabetes
May cause excessive fluid loss, leading to intense
thirst, dehydration, and weight loss
(at least 2.5[2] or 3[3] L over 24 hours in adults).
 ALTERED URINE PRODUCTION
• OLGURIA
- Oliguria = lass tha 500 ml per day or 30 ml/hour
- Occurs as result of diminished blood supply to
the kidneys
- Dimished blood supply may be due to low blood
volume or poor blood flow (e.g. hypertension)
• ANURIA
- Lack of urine production
- Kidney failure – dialysis needed
 ALTERED URINARY ELIMINATION
• Urinary frequency – voiding at frequent
intervals, that is more than 4-6 times per day
• Possible causes
- Drinking too much fluid
- Caffeine
- Alcohol
- Normal aging
 ALTERED URINARY ELIMINATION
• Nocturia – voiding two or more times at night
- Usually expressed in terms of the number of
times a person gets out of bed to void
- E.g. nocturia x 4
- Common causes
• Heart failure - fluid retained in the legs is
reabsorbed when lying down and must be
excreted.
• Cystitis
• UTI
 ALTERED URINARY ELIMINATION
• Dysuria
- Painful or difficult voiding
- May cause urinary hesitancy (delay and difficulty in
initiating voiding)
• Enuresis
- involuntary urination in children beyond the age when
voluntary bladder control is normally acquired , usually
4-5 years of age
- Nocturnal enuresis affects boys mature at a slower
pace than girls more than girls
- What do you call enuresis at morning? Diurnal
(pathologic cause)
The DOsIf your child has enuresis, you should avoid excessive
criticism of him/her.
• Your child should avoid liquids in the evening, and urinate at
specified times (e.g., after dinner, before leaving house, before
bedtime).
• Give your child positive reinforcement for "dry" nights.
The DON'TsDon't "baby" or smother your child (infantilization)
because this will only increase dependency.
When to Call Your Doctor
• If daytime wetting occurs in a child who initially only wet the bed
at night.
• If urine produced is foul smelling, blood tinged, or associated with
pain.
• You should also call your doctor if the bedwetting stops. He likes to
hear good news too
 Enuresis
• Urinary incontinence
- Involuntary urination
- Symptom not a disease
 Urinary retention
• Bladder becomes overdistended from
impaired emptying of the bladder
 Neurogenic bladder
• Impaired neurologic functioning
• Person does not perceive bladder fullness and
is unable to control urinary sphicters
 Urinary incontinence
• happens when muscles are too weak or too
active
• Common causes = pregnancy, childbirth and
menopause
• Too weak = stress incontinence
• Too strong = urge incontinence
 Urinary incontinence
• Types
• Urge Incontinence
• lose of urine for no apparent reason while suddenly feeling the
need or urge to urinate
• common cause of urge incontinence is inappropriate bladder
contractions.
• "unstable," "spastic," or "overactive bladder“
• Your doctor might call your condition "reflex incontinence" if it
results from overactive nerves controlling the bladder.
• bladder empties during sleep, after drinking a small amount of
water, or when you touch water or hear it running (as when
someone else is taking a shower or washing dishes).
• can occur because of damage to the nerves of the bladder, to the
nervous system (spinal cord and brain), or to muscles themselves.
 Urinary incontinence
• Types
• Functional Incontinence
• People with functional incontinence may have problems
thinking, moving, or communicating that prevent them
from reaching a toilet.
• A person with Alzheimer's disease, for example, may not
think well enough to plan a timely trip to a restroom.
• A person in a wheelchair may be blocked from getting to a
toilet in time.
• Conditions such as these are often associated with age and
account for some of the incontinence of elderly women in
nursing homes.
 Urinary incontinence
• Types
• Overflow Incontinence
• If your bladder is always full so that it
continually leaks urine, you have overflow
incontinence.
• Mixed Incontinence: Usually the occurrence
of stress and urge incontinence together
• Transient Incontinence: Leakage that occurs
temporarily because of a condition that will
pass (infection, medication)
 NURSING care plan
• ursing Diagnosis: Impaired Urinary Elimination - All Types of Incontinence
Stress Incontinence; Urge Incontinence; Reflex Incontinence; Functional
Incontinence; Total Incontinence
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Urinary Continence
* Urinary Elimination
* Self-Care: Toileting
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Urinary Catheterization
* Urinary Catheterization: Intermittent
* Urinary Habit Training: Urinary
* Incontinence Care
 Therapeutic Interventions
• Education/Continuity of Care
* Teach patient or caregiver normal anatomy of genitourinary
tract and factors that normally control micturition and maintain
continence.
* Assist patient in recognizing that any episodes of incontinence
that pose a social or hygienic problem deserve investigation so
that appropriate therapy can be implemented.
* Inform patient of the high incidence of urinary incontinence -
decrease feelings of hopelessness and isolation
* Assist patients, through careful interview, to identify possible
causes for urinary incontinence.
* Teach patients the necessity, purpose, and expected results of
urodynamic diagnostic evaluation.
• Urodynamic studies evaluate bladder filling and sphincter activity
and are particularly useful in differentiating stress and urge
incontinence.
• History-taking
• Take a history from the person identified to have
Urinary Incontinence (UI).
• Physical examination
• Conduct systematic physical examination to identify
abnormalities that have a bearing on the incontinence.
• Assess skin condition around the genital-perineal
region and check for excoriation.
• determine patient’s mobility, cognition
• Assess functional state.
• Habit training
• Habit training is recommended for patient in whom a natural voiding
pattern can be determined.
• Prompted voiding
• Prompted voiding is recommended for patients who can learn to recognise
some degree of bladder fullness or the need to void, or who can ask for
assistance or respond when prompted to void. Patient is asked at regular
intervals regardless whether voiding is required and is assisted to the
toilet if the response is positive.
• When toileting is successful, reward with praise and words of
encouragement.
• Bladder training/ bladder re-education
• Bladder training is strongly recommended for management of urge UI.
• Bladder training is recommended for management of stress UI.
• Direct observation of leakage
• Instruct patient to cough forcefully when the bladder is full and observe
for urine leakage.
• Urinalysis
• Send a sample of urine for urinalysis and culture.
• Measurement of residual volume
• Measure Post Voided Residual (PVR) volume by in-out catheterisation or
bladder scanning within a few minutes after voiding.
• Bladder chart/ Intake-and-output chart
• Record frequency, timing and amount of fluid intake and voiding for a few
days.
• Timed voiding/ scheduled toileting
• Timed voiding/scheduled toileting is recommended throughout the whole
day for patient who needs assistance in toileting.
• Pelvic floor muscle exercise
• Pelvic floor muscle exercise is beneficial to women with stress
incontinence. It also enhances the benefits of other therapy.
• Sustain a contraction of the perivaginal muscles or anal sphincter
for at least
• 10 seconds followed by equal periods of relaxation. Perform this 30
to 80 times a day for at least 8 weeks or until desired muscle tone is
achieved.
• Intermittent urinary catheterisation
• Intermittent catheterisation is recommended as a supportive
measure for patients with spinal cord injury, persistent UI, chronic
urinary retention due to under-active or partially obstructed
bladder.
• Indwelling urinary catheterisation
• Indwelling catheter is recommended for patient with obstructive
cause where also useful for the terminally ill; or other interventions
are not feasible. It is patient with pressure ulcers, or for severely
impaired individual in whom alternative interventions are not
suitable. It may also be used when a caregiver is not available to
provide other supportive measures.
• The patient is assessed periodically for voiding trials or bladder
training.
• External collection systems
• Uro-sheaths are recommended for incontinent men who have
adequate bladder emptying and intact genital skin, and in whom
other therapies have failed or are not appropriate.
• Absorbent products
• Skin care
• Inspect genital-perineal area daily. Identify signs of contact
dermatitis and skin excoriation.
• Cleanse skin immediately after urine leakage.
• Use appropriate skin cleansers and barrier creams.
• Dietary and fluid management
• Encourage adequate fluid and fibre intake. Reduce caffeine intake
(e.g. coffee, tea, colas).
• Patient and caregiver education
• The public should be informed that UI is not inevitable or shameful.
UI is Patient education should be individualised, treatable, if not, it
is manageable. involving caregivers and others.
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