Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 31
Urinary Elimination and Care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinary System
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Kidney—2
Ureters—2
Bladder
Urethra
Urinary meatus
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinary Conditions
 Dysuria: painful or difficult urination
 Nocturia: waking at night to urinate
 Oliguria: urinary output less than 30 mL per
hour
 Polyuria: urinary output greater than 3,000 mL
per day
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Urinary Elimination
 Urine
 95% water
 5% solutes
 Dissolved in the water
 Waste products resulting from cellular metabolism
 Accumulate in blood
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinary Waste Products
 Urea: results from amino acid metabolism
 Uric acid: results from breakdown of
ribonucleic acid (RNA) and deoxyribonucleic
acid (DNA)
 Creatinine: the waste product of muscle
metabolism
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Urinary Elimination
 Kidneys filter waste products from the blood
 Eliminate in urine
 Waste products, excess water, excess
electrolytes, hydrogen ions that need to be
eliminated, toxins, and other substances
resulting from illness
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Characteristics of Urine
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Color: straw colored
Clarity: clear
Amount: 1,000 to 3,000 mL/day
Odor: mild; slightly aromatic
pH: 4.6 to 8.0
Specific gravity: 1.010 to l.025
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Color
 Directly related to hydration level
 Normally yellow
 Darkens with decreased hydration
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Clarity
 Normally clear
 Cloudy (increased turbidity)
 Presence of fat globules, red or white blood cells,
or bacteria
 Hematuria—blood present in urine—may be
visible or microscopic
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Cloudy
 Excessively alkaline—causing formation of crystals
 Excessively acidic—causing formation of crystals
 Sediment
 Any substance that settles to the bottom of a
liquid
 Uric acid, bacteria, mucus, and phosphates
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Cloudy
 Left sitting after the specimen is collected
 Components in urine start to break down
 If not going to be analyzed within 1 hour—should
be refrigerated
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Amount
 1,000 to 3,000 ml/24 hour
 Acceptable minimal amount of urinary output per
hour—30 ml
 Volume of urine excreted (when fluids and
electrolytes are balanced) should be within
approximately 300 to 500 ml of total intake
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Oliguria
 Urinary output of <30ml/hr
 Causes—decreased fluid intake, dehydration,
illness, urinary obstruction, renal failure,
hemorrhage, or severe loss of body fluids (burns)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Polyuria
 Urinary output >3,000ml/day
 Causes—excessive fluid intake, consumption of
alcohol (affecting kidneys ability to reabsorb
water), certain medications (diuretics)—Lasix and
hydrocholorthiazide (HCTZ)
 Monitor lab values—Lasix (K+), on a potassium
supplement
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Anuria
 Absence of urine or minimal urine production
 Causes—result of temporary illness (vomiting and
diarrhea due to a virus), urinary tract obstruction,
or symptoms of serious underlying condition
(kidney failure)
 Dialysis—machine filters waste and removes
excess fluid from blood
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Urine
 Specific gravity
 Result of comparing the weight of a substance
with an equal amount of water
 Normal specific gravity?
 High specific gravity—urine more concentrated
 Low specific gravity—urine more dilute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
The nurse collecting a urine specimen from a
patient knows that crystals may be in the
urine due to which of the following?
A. White blood cells
B. Red blood cells
C. Bacteria
D. Increased pH
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessing Urine
 Physical assessment
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Color and clarity
Odor?
Volume
Edema?
 Hands, legs, feet, sacrum, and face
 Daily weight
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessing Urine
 Frequency
 Note any changes
 Complaints?
 Burning or difficulty starting stream
 Dysuria—painful or difficult urination
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinalysis
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Table 31-1
Color and appearance
pH
Specific gravity
Odor
Bacteria
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinalysis
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Protein
Leukocyte esterase
Nitrites
Glucose
Ketones
White blood cells
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinalysis
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White blood cell casts
Red blood cells
Red blood cells casts
Crystals
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Timed Urinary Collection
 24 hour urine collection
 All the urine produced within the 24 hour
collection time must be collected in specimen
jug
 If only one void is skipped—the 24 hour
collection must be restarted!
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for 24 Hour Urine
 Ask patient to void—discard urine—note
time—starting time of urine collection
 Patient starts test with an empty bladder
 Post signs—24 hour urine in progress—
bathrom
 Keep container on ice or refrigerated
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for 24 Hour Urine
 If patient has indwelling catheter—place
catheter collection bag in a basin of ice
 24 hours after collection began—ask patient
to void—add to collection container—test
completed—send to lab—remove signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Clean-catch Midstream Urine
 Do not touch inside of specimen container
 Female—spread labia—cleanse front to
back—three times—keep labia separated—
begin to void in toilet—catch urine
midstream—remove specimen cup—continue
to void in toilet
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Clean-catch Midstream Urine
 Male—retract foreskin if present—cleanse tip
of penis from meatus outward until entire
glans is cleansed—repeat three times—each
time with new wipe—begin to void in toilet—
catch urine midstream—remove specimen
cup—continue to void in toilet
 Specimen properly labeled—send to lab-document
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Reagent Testing
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Dipsticks
Immediate results
Must be read at specified times
Compare color changes on pads to chart on
the side of dipstick container
 Figure 31-2, pg. 716, Box 31-1, pg. 716
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Straining Urine
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Renal calculi (kidney stones)
Can occur anywhere in urinary tract
Retain any placed stone
Send to lab for analysis
STRAIN ALL URINE
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Intake and Output
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Measure fluid taken in
Measure fluid coming out
Assess for balance per shift and per 24 hr
Specimen pan, urinal—marked in mls.
Bedpan or bedside commode—empty into
specimen pan—measure—avoid placing toilet
tissue in with urine
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Alterations in Urinary Function
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Bladder does not empty completely
Unable to initiate urinary stream
Urine released involuntarily
Blockages
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urinary Retention
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Inability to empty bladder
Inability to completely empty the bladder
Acute or chronic
Normal function til reaches bladder
If not relieved—reflux to kidneys—
hydronephrosis—renal damage
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Urinary Retention
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Kidney stones
Enlarged prostate gland
Tumor
Pregnant uterus
Infection or scar tissue
Nerve disorders
Postoperative complications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Residual Urine
 Urine that remains in the bladder after voiding
 Maximum amount of urine left in bladder
after voiding 100 ml
 Palpate bladder—just above symphysis
pubis—distention?
 Bladder scan—Figure 31-4
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bladder Scan Demo
 http://www.youtube.com/watch?v=1RobLmn
hoVU&feature=related
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nocturia
 Awaken during the night to urinate
 Excessive fluid intake
 Rule out—congestive heart failure,
uncontrolled diabetes mellitus, UTI, enlarged
prostate, or kidney disease
 Talk with your doctor
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Types of Incontinence
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Stress—increased intra-abdominal pressure
Urge—overactive bladder
Overflow—obstruction
Functional—unable to reach a bathroom
Total—unaware of need to void
Neuropathic—nerve damage
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Stress Incontinence
 Coughing, sneezing, laughing, heavy lifting…..
 Vaginal births, surgery, genetics, hormones
 Pelvic floor muscles become weak
 increased intra-abdominal pressure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Urge Incontinence
 Inability to keep urine in the bladder to reach
a bathroom--overactive bladder
 Void more frequently
 Hear water running, hands in warm water,
drinking liquid
 Bladder spasms
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Overflow Incontinence
 Bladder distended--obstruction
 Urine leaking past the obstruction
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Incontinence
 Functional—inability to reach bathroom in
time
 Total—loss of urine with no warning
 Neuropathic—nerve damage
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
True/False Question
The nurse caring for patients in a long-term
care setting knows that urinary incontinence is
a normal part of the aging process.
A. True
B. False
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Managing Incontinence
 Stress incontinence
 Kegel exercises
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Box 31-2, pg. 718
Tighten pelvic floor muscles
Hold contraction 5 to 10 seconds
Relax for 5 to 10 seconds
40 to 60 times throughout the day
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Initiating Bladder Training
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Ensure adequate amount of fluids
Avoid caffeinated beverages
Drink more during a.m. and less in p.m.
Offer fluids throughout the day; avoid large
volume at one time
 Provide regular opportunities for toileting
 Mimic patients’ normal voiding patterns
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Not a Candidate
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Good skin care
Prevent breakdown
Change brief and perform perineal care q2h
Indwelling catheters are not used for
incontinence
 Can lead to UIT’s, sepsis, urethral strictures,
prostatitis, and potential for bladder cancer
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assisting Patients With Toileting
 Offer opportunity to use bathroom/bedpan before
and after meals and at bedtime
 Allow male patients to void standing up if not
contraindicated
 Use a fracture pan for patients with hip or back
surgeries
 Provide privacy and avoid rushing
 Offer hand hygiene after toileting
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Type of Catheters and Uses
 Straight (single lumen)
 One-time drainage or sterile specimen
 Indwelling (double lumen or Foley)
 Urine drainage for a specified amount of time
 Three-way (triple lumen or Alcock)
 Transurethral resection
 Condom (Texas)
 Male urinary incontinence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Care of the Urinary Drainage Bag
 Empty every 8 hours and document amount
 Do not touch drainage spout to any surface and wipe
with alcohol before closing
 Always empty urine in a graduate to measure it
 Maintain bag below the level of the bladder
 Keep tubing free of kinks and coils
 Hang on bed; do not rest on floor
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Catheter Care
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At least once a shift
Anytime catheter is contaminated by a BM
Soap and water
Cleanse perineum
From insertion site down catheter
Do not pull or tug on catheter
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
A nurse prepares a patient for the
procedure to obtain a sterile urine sample.
Which of the following catheters would be
used?
A. Straight
B. Indwelling
C. Suprapubic
D. Condom
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Read…………….
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Skill 31-1, pg. 731
Skill 31-2, pg. 731-732
Skill 31-1, pg. 732-733
Skill 31-8, pg. 740
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Skill 31-1 Urinal
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Check activity level
Prefer standing or sitting
Need assistance?
Gather supplies
Place urinal between legs—place penis inside
the urinal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Skill 31-1 Urinal
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When finished—offer hand hygiene
Measure amount, assess color, clarity, odor
How was urinary stream?
Any burning, discomfort, difficultly starting,
during, or at end?
 Empty urinal, rinse, return to appropriate
location—I&O if needed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Skill 31-2 Bedpan
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Review activity level
What type of bedpan?
Gather supplies
Clean gloves
Roll patient to one side—place bedpan firmly
against the buttocks—assist patient to roll
onto back and bedpan
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Skill 31-2 Bedpan
 Fracture pan—patient may be able to raise
hips and not have to turn—trapeze and lift
up—place fracture pan
 Raise head of bed (HOB) unless
contraindicated
 If patient able—provide privacy and supplies
and call bell
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Skill 31-2 Bedpan
 If on I&O—no toilet paper in bedpan
 Carefully support bedpan—to prevent
spilling—have patient lift up or turn on side to
remove bedpan
 Offer hand hygiene
 Provide perineal care if needed
 Clean bedpan—remove gloves—wash hands
Copyright © 2011 F.A. Davis