Urinary Urinary EliminationElimination

Teresa V. Hurley, MSN, RNTeresa V. Hurley, MSN, RN

Urinary SystemUrinary System

Kidneys filter nitrogen, metabolic Kidneys filter nitrogen, metabolic wastes, excess ions and waterwastes, excess ions and water

Urine produced at a rate of 60 Urine produced at a rate of 60 mL/hourmL/hour

Bladder stores average 500 mL or Bladder stores average 500 mL or moremore

Void: detrusor muscle contracts and Void: detrusor muscle contracts and urine is pushed through internal urine is pushed through internal urethral sphincter into urethraurethral sphincter into urethra

UrinalysisUrinalysis

Urine: clear, yellow, aromatic, Urine: clear, yellow, aromatic, without pathogens or parasiteswithout pathogens or parasites

Specific Gravity: 1.025 (concentrate Specific Gravity: 1.025 (concentrate urine)urine) Increases with dehydrationIncreases with dehydration Decreases with increased fluid intakeDecreases with increased fluid intake

UrinalysisUrinalysis AbnormalAbnormal

Protein: renal disease, 2Protein: renal disease, 2ndnd to exercise and stress to exercise and stress Glucose: elevated BS; diabetesGlucose: elevated BS; diabetes Ketones: CHO metabolismKetones: CHO metabolism

Diabetes, fever, fasting, starvation, high protein intake, Diabetes, fever, fasting, starvation, high protein intake, vomiting, post-opvomiting, post-op

Hemoglobin: UTI, nephritis, trauma, lithiasis, Hemoglobin: UTI, nephritis, trauma, lithiasis, hemolytic rxhemolytic rx

Bilirubin: liver diseaseBilirubin: liver disease Urobilinogem: cirrhosis, heart failure, pernicious Urobilinogem: cirrhosis, heart failure, pernicious

anemia, monoanemia, mono Nitrates: bacteriaNitrates: bacteria Leukocyte esterase: bacteria, fungal, parasitic, Leukocyte esterase: bacteria, fungal, parasitic,

tumor, nephritistumor, nephritis

HematologicalHematological

Hematological Hematological BUN 8-16 mg/dL (end product protein BUN 8-16 mg/dL (end product protein metabolism)metabolism)Creatinine 0.6-1.2mg/dL (muscle Creatinine 0.6-1.2mg/dL (muscle metabolism of creatin)metabolism of creatin)

Increased: renal failure, infection, Increased: renal failure, infection, obstruction, dehydration, increase protein obstruction, dehydration, increase protein intake, TPNintake, TPN

Decreased: liver disease, decrease protein Decreased: liver disease, decrease protein intakeintake

Factors Affecting Factors Affecting MicturitionMicturition

Developmental considerationsDevelopmental considerations Food and fluid intakeFood and fluid intake Psychological variablesPsychological variables Activity and muscle toneActivity and muscle tone Pathologic conditionsPathologic conditions MedicationMedication

Developmental Developmental ConsiderationsConsiderations

ChildrenChildren Toilet training 18 to 24 months, Toilet training 18 to 24 months,

enuresisenuresis Effects of agingEffects of aging

Nocturia, increased frequency, urine Nocturia, increased frequency, urine retention and stasis, voluntary control retention and stasis, voluntary control affected by physical problemsaffected by physical problems

Effects of Medications on Effects of Medications on Urine Urine

Production and EliminationProduction and Elimination Diuretics — prevent Diuretics — prevent

reabsorption of reabsorption of water and certain water and certain electrolytes in electrolytes in tubulestubules

Cholingeric Cholingeric medications — medications — stimulate contraction stimulate contraction of detrusor muscle, of detrusor muscle, producing urinationproducing urination

Analgesics and Analgesics and tranquilizers — tranquilizers — suppress CNS suppress CNS diminish diminish effectiveness of effectiveness of neural reflexneural reflex

Medications Affecting Color Medications Affecting Color of Urineof Urine

Anticoagulants — red colorAnticoagulants — red color Diuretics — lighten urine to pale Diuretics — lighten urine to pale

yellowyellow Pyridium — orange to orange-red Pyridium — orange to orange-red

urineurine Elavil — green or blue-greenElavil — green or blue-green Levodopa — brown or blackLevodopa — brown or black

Using the Nursing Using the Nursing ProcessProcess

Assessing data about voiding Assessing data about voiding patterns, habits, past history of patterns, habits, past history of problemsproblems

Physical examination of urinary Physical examination of urinary system, skin hydration, urinesystem, skin hydration, urine

Correlation of these findings with Correlation of these findings with results of procedures and diagnostic results of procedures and diagnostic teststests

Assessing a Problem With Assessing a Problem With VoidingVoiding

Explore its duration, severity, and Explore its duration, severity, and precipitating factors.precipitating factors.

Note client’s perception of the Note client’s perception of the problem.problem.

Check adequacy of client’s self-care Check adequacy of client’s self-care behaviors.behaviors.

Physical Assessment of Physical Assessment of Urinary FunctioningUrinary Functioning

Kidneys — check Kidneys — check for costovertebral for costovertebral tendernesstenderness

Urinary bladder — Urinary bladder — palpate and palpate and percuss the percuss the bladder or use bladder or use bedside scannerbedside scanner

Urethral meatus — Urethral meatus — inspect for signs of inspect for signs of infection, infection, discharge, or odordischarge, or odor

Skin — assess for Skin — assess for color, texture, color, texture, turgor, and turgor, and excretion of wastesexcretion of wastes

Urine — assess for Urine — assess for color, odor, clarity, color, odor, clarity, and sedimentand sediment

Measuring Urine OutputMeasuring Urine Output

Ask client to void Ask client to void into bedpan, into bedpan, urinal, or specimen urinal, or specimen container in bed or container in bed or bathroom.bathroom.

Pour urine into Pour urine into appropriate appropriate measuring device.measuring device.

Place calibrated Place calibrated container on flat container on flat surface and read at surface and read at eye level.eye level.

Note amount of Note amount of urine voided and urine voided and record on record on appropriate form.appropriate form.

Discard urine in Discard urine in toilet unless toilet unless specimen is needed.specimen is needed.

Urine SpecimensUrine Specimens

Routine urinalysisRoutine urinalysis Specimens from infants and childrenSpecimens from infants and children Clean-catch or midstream specimensClean-catch or midstream specimens Sterile specimens from indwelling Sterile specimens from indwelling

cathetercatheter 24-hour urine specimen24-hour urine specimen

Promoting UrinationPromoting Urination

Maintaining voiding habitsMaintaining voiding habits Promoting fluid intakePromoting fluid intake Strengthening muscle toneStrengthening muscle tone

Kegel Exercises (PFME) to Tx stress, urge Kegel Exercises (PFME) to Tx stress, urge mixedmixed

Imagine voiding, stop flow, tighten rectal Imagine voiding, stop flow, tighten rectal musclesmuscles

Hold 5-10sec and rest 5-10secHold 5-10sec and rest 5-10sec Daily 40-60 PFME doing 2-4 sets of 15 each timeDaily 40-60 PFME doing 2-4 sets of 15 each time

Client’s at Risk for UTIsClient’s at Risk for UTIs

Sexually active womenSexually active women Postmenopausal womenPostmenopausal women Individuals with indwelling urinary Individuals with indwelling urinary

cathetercatheter Individual with diabetes mellitusIndividual with diabetes mellitus Elderly peopleElderly people

Four Types of Urinary Four Types of Urinary IncontinenceIncontinence

Stress — increase in intraabdominal Stress — increase in intraabdominal pressurepressure

Urge — urine lost during abrupt and Urge — urine lost during abrupt and strong desire to voidstrong desire to void

Mixed — symptoms of urge and stress Mixed — symptoms of urge and stress incontinence presentincontinence present

Overflow — overdistention and Overflow — overdistention and overflow of bladderoverflow of bladder

Functional — caused by factors Functional — caused by factors outside the urinary tractoutside the urinary tract

Client Education for Client Education for Urinary DiversionUrinary Diversion

Explain reason for diversion and Explain reason for diversion and rationale for treatmentrationale for treatment

Demonstrate effective self-care behaviorsDemonstrate effective self-care behaviors Describe follow-up care and support Describe follow-up care and support

resourcesresources Report where supplies may be obtained Report where supplies may be obtained

in communityin community Verbalize related fears and concernsVerbalize related fears and concerns Demonstrate a positive body imageDemonstrate a positive body image

Evaluating Effectiveness Evaluating Effectiveness of Planof Plan

Maintain fluid, electrolyte, and acid-Maintain fluid, electrolyte, and acid-base balancebase balance

Empty bladder completely at regular Empty bladder completely at regular intervals with no discomfortintervals with no discomfort

Provide care for urinary diversion and Provide care for urinary diversion and when to notify physicianwhen to notify physician

Develop a plan to modify factors Develop a plan to modify factors contributing to problemcontributing to problem

Correct unhealthy urinary habitsCorrect unhealthy urinary habits

Hazards of Hazards of CatheterizationCatheterization

UTI.UTI. Sepsis.Sepsis. Trauma- specially Trauma- specially

in men. in men.

DO NOT USE DO NOT USE FORCE!FORCE!

USE STERILE USE STERILE ASEPTIC ASEPTIC TECHNIQUE!TECHNIQUE!

ResearchResearch clean technique can clean technique can

be used for self be used for self catheterization at catheterization at home.home.

Reasons for Reasons for CatheterizationCatheterization

Relieving urinary retention.Relieving urinary retention. Obtaining a sterile urine specimen..Obtaining a sterile urine specimen.. Emptying the bladderEmptying the bladder

before,before, during, during, after surgery or diagnostic procedures.after surgery or diagnostic procedures.

Monitoring of critically ill patients.Monitoring of critically ill patients.

Types of CathetersTypes of Catheters

Indwelling catheterIndwelling catheter remains in place for remains in place for

continuous drainage.continuous drainage. Intermittent catheterIntermittent catheter

used to drain bladder used to drain bladder for short periods of for short periods of time.time.

Suprapubic catheterSuprapubic catheter inserted surgically inserted surgically

above the pubic bone above the pubic bone for continuous for continuous drainage.drainage.

Urinary DiversionsUrinary Diversions

UreterostomyUreterostomy Bladder is removedBladder is removed One or both ureters redirected from One or both ureters redirected from

kidney through the abdominal wallkidney through the abdominal wall

Ileal ConduitIleal Conduit

Bladder removed and small intestine Bladder removed and small intestine (ileum) used as conduit between (ileum) used as conduit between ureters and skin surface. Urine ureters and skin surface. Urine collects continuouslycollects continuously

Client Care Goals:Client Care Goals:Interventions Indwelling Interventions Indwelling

CatheterCatheter Prevent UTI (meatus burning, cloudy, foul, chills, fever)Prevent UTI (meatus burning, cloudy, foul, chills, fever)

Maintain closed systemMaintain closed system Cleanse catheter soap/H2O; pat dryCleanse catheter soap/H2O; pat dry Alcohol swab for contaminationAlcohol swab for contamination Empty bag q 8 h or moreEmpty bag q 8 h or more Bag below bladder levelBag below bladder level Maintain urine acidity: cranberry juice, prunes, plums, Maintain urine acidity: cranberry juice, prunes, plums,

tomatoes, eggs,meat, cheese, citrus fruitstomatoes, eggs,meat, cheese, citrus fruits Change only sediment collects, sandy particles, trouble Change only sediment collects, sandy particles, trouble

drainingdraining

Maintain Urine Flow ( prevent urinary stasis and backflow)Maintain Urine Flow ( prevent urinary stasis and backflow) Gravity drainageGravity drainage Check for kinks, coils, lying on tube Check for kinks, coils, lying on tube Clamp if higher than bladderClamp if higher than bladder Do not allow on floorDo not allow on floor

Client GoalsClient Goals Prevent Infection TransmissionPrevent Infection Transmission

Wash hands before and afterWash hands before and after Wear glovesWear gloves

Promote Urine Production (pathogen Promote Urine Production (pathogen flushing; tube irrigation; prevents stasis)flushing; tube irrigation; prevents stasis) Oral intake 8-10 glasses (3000 mL/day) unless Oral intake 8-10 glasses (3000 mL/day) unless

contra-indicatedcontra-indicated Parenteral or Enteral feedingsParenteral or Enteral feedings Monitor I & O q 8 hMonitor I & O q 8 h Check for blood, sediments, color, odorCheck for blood, sediments, color, odor

Client GoalsClient Goals

Maintain Skin and Mucosal IntegrityMaintain Skin and Mucosal Integrity Prevent fecal and encrustation to Prevent fecal and encrustation to

catheter and perineal areacatheter and perineal area Cleasnse: soap/H2OCleasnse: soap/H2O Sandy particle encrustation at the Sandy particle encrustation at the

meatus (catheter change) meatus (catheter change)