Urinary Elimination

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 Scientific Knowledge Base

 Kidneys
 Ureters
 Bladder
 Urethra

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 Quick Quiz!

1. A patient with a long-standing history of

diabetes mellitus is voicing concerns about
kidney disease. The patient asks the nurse
where urine is formed in the kidney. The
nurse’s response is the:
A. bladder.
B. kidney.
C. nephron.
D. ureter.

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 Case Study
 Mrs. Vallero is a 65-year-old woman who has been in the
hospital for 4 days with problems related to heart failure,
fluid retention, and diabetes. She has a history of urinary
retention secondary to neuropathy caused by her
diabetes.
 Mrs. Vallero’s indwelling urinary catheter was removed 2
days ago and subsequently was replaced yesterday at 6
a.m. because of her inability to urinate more than 100 mL
at a time, being incontinent of small amounts of urine,
complaints of urinary urgency, and lower abdominal pain.

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 Act of Urination

 Brain structures influence bladder function.

 Voiding: Bladder contraction + urethral sphincter
and pelvic floor muscle relaxation
 1. Bladder wall stretching signals micturition center.
 2. Impulses from the micturition center in the brain
respond to or ignore this urge, thus making urination
under voluntary control.
 3. When a person is ready to void, the central
nervous system sends a message to the micturition
centers, the external sphincter relaxes and the
bladder empties.

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 Factors Influencing Urination

 Growth and development

 Sociocultural factors
 Psychological factors
 Personal habits
 Fluid intake
 Pathological conditions
 Surgical procedures
 Medications
 Diagnostic Examinations
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 Case Study (Cont.)
 Sandy notes that the urinary catheter was removed at 7
a.m. this morning, and the patient has no recorded urine
output for the day. Mrs. Vallero verifies that she has only
“dribbled” urine. While making rounds, Sandy talks with
Mrs. Vallero, who says she is worried because “I thought
this was all under control.”
 The health care provider is notified, and an order is
obtained for an intermittent catheterization. The
registered nurse on the day shift catheterizes Mrs.
Vallero at 3 p.m. with a return of 600 mL of pale, clear
yellow urine.

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 Case Study (Cont.)
 As Sandy prepares to assess Mrs. Vallero again, she
remembers that urinary problems are common in
patients who have diabetes and in older adults. Age
alone does not cause incontinence. She recalls that
patients with urinary retention sometimes leak or
“dribble” urine and are then misdiagnosed as incontinent.
 She knows that patients generally void at least every 6 to
8 hours, and that Mrs. Vallero’s recent catheterization,
her decreased mobility, and her history of diabetes make
her more prone to urinary retention, incontinence of
small amounts of urine, and urinary tract infection (UTI).

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Common Urinary Elimination Problems

 Urinary retention
 An accumulation of urine due to the inability of the
bladder to empty
 Urinary tract infection
 Results from catheterization or procedure
 Urinary incontinence
 Involuntary leakage of urine

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Common Urinary Elimination Problems
(Cont.)
 Urinary diversion
 Diversion of urine to
external source

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Common Urinary Elimination Problems
(Cont.)
 Nephrostomy tubes
 Small tubes tunneled
through the skin into
the renal pelvis
 Placed to drain the
renal pelvis when the
ureter is obstructed

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 Quick Quiz!

2. A health care provider may suspect that a

patient is experiencing urinary retention
when the patient has:
A. large amounts of voided cloudy urine.
B. pain in the suprapubic region.
C. spasms and difficulty during urination.
D. small amounts of urine voided two to three
times per hour.

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 Case Study (Cont.)
 Sandy knows that she will need to assess whether Mrs.
Vallero feels the urge to urinate. She determines that no
one has taken Mrs. Vallero to the bathroom recently.
Sandy also needs to find out more about her patient’s
urination patterns at home because Mrs. Vallero has
verbalized anxiety about her present voiding patterns.
 Previous clinical experience has taught Sandy that
palpation of the abdomen over a distended bladder
causes some discomfort, and that the patient often
experiences an urge to urinate. Mrs. Vallero grimaces
when her abdomen is palpated and says she has a little
dolor (pain).

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 Nursing Knowledge Base

 Infection control and hygiene

 Growth and development
 Psychosocial considerations

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 Critical Thinking

 Successful critical thinking requires synthesis of

 Knowledge
 Experience
 Information gathered from patients
 Critical thinking attitudes
 Intellectual and professional standards

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 Nursing Process: Assessment

 Through the patient’s eyes

 Self-care ability
 Cultural considerations
 Health literacy
 Nursing history
 Pattern of urination
 Symptoms of urinary alterations

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 Assessment (Cont.)

 Physical assessment
 Kidneys
 Bladder
 External genitalia and urethral meatus
 Perineal skin

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 Assessment (Cont.)

 Assessment of urine
 Intake and output
 Characteristics of urine
• Color
• Clarity
• Odor

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 Case Study (Cont.)

 Findings:
 Patient is able to palpate bladder, indicating bladder
distention. During palpation, patient states she has
the sensation of bladder fullness.
 Patient complains of dribbling frequently and being
unable to urinate.

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 Quick Quiz!

3. A young girl is having problems urinating

postoperatively. You remember that children
may have trouble voiding:
A. in bathrooms other than their own.
B. in a urinal.
C. while lying in bed.
D. in the presence of a person other than one of
their parents.

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 Laboratory and Diagnostic Testing

 Nursing responsibilities before testing:

 Ensure a signed consent is completed.
 Assess the patient for any allergies.
 Administer bowel-cleansing agents as ordered.
 Ensure that the patient adheres to the appropriate
pretest diet or nothing by mouth (NPO).
 Responsibilities after testing include:
 Assessing I&O
 Assessing voiding and urine
 Encouraging fluid intake

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 Nursing Diagnosis

 Nursing diagnoses common to patients with

urinary elimination problems:
 Functional urinary incontinence
 Stress urinary incontinence
 Urge urinary incontinence
 Risk for infection
 Toileting self-care deficit
 Impaired skin integrity
 Impaired urinary elimination
 Urinary retention

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 Planning

 Goals and outcomes

 Set realistic and individualized goals along with
relevant outcomes
 Collaborate with the patient
 Setting priorities
 Patient’s immediate physical and safety needs
 Patient expectations and readiness to perform some
self-care activities
 Teamwork and collaboration

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 Case Study (Cont.)

 Nursing diagnosis: Urinary retention related to

weakened detrusor muscle and recent removal
of indwelling urinary catheter.
 Goal: Mrs. Vallero will have normal micturition
within 1 month.

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 Implementation

 Health promotion
 Patient education
 Promoting normal
micturition
• Maintaining elimination
habits
• Maintaining adequate
fluid intake
 Promoting complete
bladder emptying
 Preventing infection

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 Case Study (Cont.)

 Interventions for urinary retention care include:

 Assist with toileting every 2 to 3 hours while awake.
 Instruct the patient/family to record urinary output as
appropriate.
 Have Mrs. Vallero take a warm bath if unable to
urinate.
 Use Credé’s method with each attempted void.

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 Implementation (Cont.)

 Acute care
 Catheterization
• Types of catheters

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 Implementation (Cont.)

 Catheterization
(Cont.)
 Catheter sizes

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 Implementation (Cont.)

 Catheterization
(Cont.)
 Catheter drainage
systems
 Routine catheter care

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 Implementation (Cont.)

 Catheterization
(Cont.)
 Preventing catheter
associated infection
 Catheter irrigations
and instillations

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 Implementation (Cont.)

 Removal of indwelling
catheters
 Alternatives to
catheterization
 Suprapubic catheters
 External catheters

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 Implementation (Cont.)

 Urinary diversions
 Incontinent diversions
• Changing a pouch
 Gently cleanse the skin surrounding the stoma
 Measure the stoma and cut the opening in the pouch
 Remove the adhesive backing and apply the pouch
 Press firmly into place over the stoma.
 Observe the appearance of the stoma and surrounding skin.
 Continent diversions
 Orthopic neobladder

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 Implementation (Cont.)

 Medications
 Antimuscarinics: treat urgency, frequency, nocturia
and urgency UI
 Bethanechol: treat urinary retention
 Tamsulosin and silodosin: relax smooth muscle
 Finasteride and dutasteride: shrink the prostate
 Antibiotics: treat urinary tract infections
 Be familiar with the medications and indications
for all medications your patient is taking.

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 Implementation (Cont.)

 Continuing and
restorative care
 Lifestyle changes
 Pelvic floor muscle
training
 Bladder retraining
 Toileting schedules
 Intermittent
catheterization
• Skin care

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 Evaluation

 Through the patient’s eyes

 Assess the patient’s self-image, social interactions,
sexuality, and emotional status
 Patient outcomes
 Use the expected outcomes developed during
planning to determine whether interventions were
effective
 Evaluate for changes in the patient’s voiding pattern
and/or presence of symptoms
 Evaluate patient/caregiver compliance with the plan

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 Case Study (Cont.)
 Sandy talks with Mrs. Vallero the next evening. The
patient’s care plan incorporates scheduled voiding, oral
fluids, and use of Credé’s method of manual
compression during voiding. She palpates Mrs. Vallero’s
bladder and assists her to the toilet.
 After making sure she is comfortable and leaving the call
light in place, Sandy instructs her to use Credé’s method
of manual compression. She returns to measure Mrs.
Vallero’s urinary output and evaluates for bladder
residual using an ultrasound bladder scan.

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 Case Study (Cont.)

 Ask Mrs. Vallero about her urge to void,

sensation of bladder fullness, and dribbling
episodes.
 Have Mrs. Vallero keep a log of her pattern of
elimination, including urine output volumes with
each voiding, during the 1-month period.
 Ask Mrs. Vallero if she continues to have lower
abdominal pain.

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 Case Study (Cont.)

 Mrs. Vallero is concerned about regaining her

urinary function. Sandy develops the following
outcome for her: At the end of the teaching
session, Mrs. Vallero will be able to describe
approaches to promote normal urinary
elimination habits.

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 Safety Guidelines for Nursing Skills

 Follow principles of surgical and medical asepsis

as indicated
 Identify patients at risk for latex allergies
 Identify patients with allergies to povidone-iodine
(Betadine). Provide alternatives such as
chlorhexidine.

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