Urinary Elimination

Dr. Belal Hijji, RN, PhD

March 17 & 18, 2012

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Learning Outcomes

After this lecture, students will be able to:

• Describe functions of the urinary system organs

• Describe factors that can affect normal urinary elimination

• Identify common urinary elimination problems and types of urinary incontinence

• Describe a nursing care plan of a client with urinary retention

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Functions of the Urinary System Organs

• Kidneys: Are reddish brown, bean-shaped organs. Nephrons are the functional units of the kidneys; they remove waste products from blood and regulate water and electrolyte concentrations in body fluids. A cluster of capillaries forms the glomerulus which is the initial site of urine formation. These capillaries filter water, amino acids, glucose, uric acid, creatinine, and electrolytes. However, they do not filter proteins and blood cells.

• Ureters: Transport urine, which is sterile, from kidneys to bladder. Peristaltic waves cause the urine to enter the bladder in spurts rather than steadily.

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• Bladder: Is a reservoir that holds urine until the urge to urinate develops. In male, it rests against the rectum posteriorly, in female it rests against the anterior wall of uterus and vagina. The bladder is a hollow, muscular organ located in the pelvis. It has a fixed base and a distensile upper portion composed of multiple bundles of smooth muscle called the detrusor muscle.

• Urethra: The passage that ends with the urethral meatus through which urine exits the body. The external urethral sphincter permits voluntary flow of urine

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Factors Affecting Urination

• Normal urinary elimination can be affected by physiological factors, psychosocial conditions, and diagnostic or treatment-induced factors. Knowledge of these factors enables the nurse to anticipate possible elimination problems.– Age: Children cannot control urination voluntarily until 18 to 24

months. The child must be able to recognise the feeling of bladder fullness, to hold urine for sometime, and to communicate the sense of urgency to parent. The process of aging may impair micturition. Problems of mobility may make it difficult for older adults to reach the toilet or bedside commode in time.

– Sociocultural factors: Cultural and gender norms vary on the privacy or publicness of urination.

– Psychological factors: Anxiety and stress may affect a sense of urgency and increase the frequency of urination. Anxiety may prevent complete urination because of tension.

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– Muscle tone: Weak abdominal and pelvic floor muscles impair bladder contraction and control of the external sphincter. Immobility, child birth, use of indwelling catheter, and trauma may decrease muscle tone.

– Fluid intake: More fluid intake increases urine production. Alcohol stops the release of the anti-diuretic hormone (ADH), thus promoting urine production. Fluids containing caffeine increase frequency of micturition.

– Pathological conditions: Acute renal disease reduces urine volume; chronic diseases initially increase volume of urine. Spinal cord injuries interrupt voluntary bladder emptying

– Surgical procedures and drugs: The stress response to surgery reduces the amount of urinary output to increase circulatory fluid volume. Anesthesia and pain killers slow the filtration rate and reduce urine output. Diuretics prevent reabsorption of water and electrolytes, and urinary output increases.

– Diagnostic tests: Cystoscopy may cause localised edema of the urethra and bladder sphincter spasm resulting in urinary retention.

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Common Urinary Elimination Problems

• Urinary retention: It is an accumulation of urine in the bladder because it cannot partially or completely empty. The client who retains at least 25% of the total bladder capacity is experiencing urinary retention. When this happens, bladder walls stretch causing feelings of pressure, discomfort, tenderness of symphysis pubis, restlessness, and diaphoresis. These findings along with an absence of urinary output over several hours and distended bladder may indicate urinary retention.

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• Urinary tract infections (UTIs): 36% to 40% of UTIs are nosocomial. The urinary catheter is a source of injury to the mucosa, thus allowing bacterial invasion. Therefore, it is important to keep catheterisation to a minimum to avoid bacteriuria. Signs and symptoms of UTI include pain or burning urination, frequent and urgent sensation of the need to void, fever, chills, nausea and vomiting, hematuria, and concentrated cloudy urine.

• Urinary incontinence: It is the loss of control over voiding. It can be temporary or permanent. Leakage maybe continuous or intermittent. Incontinence affects body image and social interaction. Urine odor and wet clothes add to the embarrassment. Urinary incontinence may result from multiple causes, including urinary tract infection, detrusor instability, bladder outlet obstruction or incompetence, neurologic impairment, bladder spasm, and inability to reach the toilet in time.

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Types of Urinary Incontinence

• Total: Total uncontrollable and continuous loss of urine. Neuropathy of sensory nerves, trauma or disease of spinal nerves or urethral sphincter cause this problem.

• Functional: Involuntary unpredictable passage of urine in client with intact urinary and nervous systems. It is caused by a fistula between bladder and vagina or a change in environment. The client has strong urge to void but loses urine before reaching the toilet. In functional incontinence, the patient has intact urinary physiology but experiencing mobility impairment or cognitive problems and is unable to reach and use the toilet before soiling him/ herself.

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• Stress: Increased intraabdominal pressure causing leakage of small amounts of urine. Causes are coughing, laughing, vomiting, or lifting with full bladder, obesity, full uterus pressing against bladder during the 3rd trimester.

• Urge: This is involuntary passage of urine after strong sense of urgency to void. Causes include alcohol or caffeine ingestion, increased fluid intake, irritation of bladder stretch receptors.

• Reflex: This is involuntary loss of urine occurring somewhat at predictable intervals when specific bladder volume is reached. Causes are upper or lower spinal cord injury. The client is unaware of bladder filling and does not feel urgency to void.

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Nursing Care Plan of a Client With Urinary Retention

• Assessment: Mr. Ali is unable to void after catheter removal. He has been catheterised once and 1100 ml of urine removed. He complains of dribbling and inability to urinate. He was incontinent on the last shift of a small amount of urine. Nursing assessment reveals a distended bladder.

• Nursing diagnosis: Urinary retention related to detruser inadequacy secondary to catheterisation.

• Planning: The goal is, “The client will have normal micturition with complete bladder emptying within 2 days. Expected outcomes are:– Client will void within 8 hours. He will void at least 300 ml with

each voiding.

– Client urine remains clear yellow

– Client will remain free of discomfort during voiding

– Client bladder remains nondistended

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• Intervention– Have the client attempt voiding at regularly scheduled times.

– Have the client use bladder compression during voiding.

– Allow client to sit on toilet for 15 minutes to encourage second voiding.

– Encourage fluid intake of 2000 ml/ day

• Evaluation – Measure and observe color of each voided specimen

– Palpate the bladder every 4 hours and after each voiding

– Ask client about sensation to void, bladder fullness, and discomfort when voiding