Urinary Elimination
 Anatomy and Physiology
 Kidneys
 Functional unit is the nephron; remove waster products from blood and regulate fluid and electrolyte
balance
 Glomerulus is a cluster of capillaries where the blood is filtered and urine is formed.
 Protein does not normally filter through, so proteinuria indicates a problem.
 _______________ connect kidney to bladder
 Bladder is a reservoir for urine
 Urethra connects bladder to urethral meatus; the external urethral sphincter permits voluntary flow of
urine
 Factors Influencing Voiding
 Growth and Development
 Children cannot control urination until 18-24 months
 Nocturnal enuresis (is a problem if > 6 yrs old)
 Elders: impaired mobility affects toileting
 Sociocultural: privacy and social expectations
 Psychological: Anxiety and stress
 Personal habits: privacy and adequate time
 Positioning! Men should stand if possible and women should be in High Fowler’s if using bedpan
 Muscle tone: Weak abdominal and pelvic floor muscles cause incontinence
 Indwelling catheter causes loss of bladder tone
 Food and fluids
 Caffeine/Alcohol: mild diuretics
 Sodium: fluid retention
 Pathologic conditions: diabetes, MS, stroke, heart and renal failure, spinal cord injuries
 Surgery: anesthetics and narcotics can cause retention
 Meds:
 Diuretics increase output (Lasix, HCTZ); Important teaching: if ordered BID, take by 3pm to avoid
nocturia
 Some change color of urine (Pyridium->orange urine)
 Terms Used
 Polyuria: void in abnormally lg amts
 Ex: Diabetes: polyuria, polydipsia, polyphagia
 Oliguria: Low urine output
 R/T Decreased fluids or impending renal failure
 Anuria: No urine output
 Dialysis: mechanism of filtering blood r/t kidney failure
 Hemodialysis and Peritoneal dialysis
 Frequency: more than usual
 Nocturia (2 or more per night)
 Urgency: feeling of need to void
 Dysuria: painful or difficult
 Hematuria: blood present
 Enuresis: Involuntary urination after age 4
 Urinary Incontinence: Symptom, not disease; can have significant impact on life. Two types:
 Stress Incontinence: Leaking on coughing, laughing, sneezing, jumping
 Urge Incontinence: Unable to retain urine long enough after urge is felt
 Potential complication: _________________
 Common Urinary Elimination Problems
 Urinary Retention: Unable to completely empty bladder -> urine accumulates-> bladder becomes
distended -> risk for UTI and incontinence
 Potential Causes of retention: prostate gland enlargement; fecal impaction; pregnancy; anesthesia
 Can assess post-void residual with bladder scan or straight catheterization; >400ml is abnormal
 Urinary Tract Infections
 =40% of nosocomial infections, most due to non-asceptic catheterization; urosepsis is a life
threatening complication; good handwashing and sterile technique during catheterization is essential
 Most common bacteria: E. coli (from colon)
 Causes: poor perineal hygiene; frequent sexual intercourse; bubble baths; residual urine
 Common symptoms: dysuria, urgency, frequency, hematuria
 If spreads to kidneys: fever, flank pain, chills
 Older adult may only show change in mental status
 Diagnostic tests: urinalysis; urine culture
 Treatment: antibiotics, antispasmodic (Pyridium)
 Urinary incontinence
 Stress Incontinence: leaking, dribbling on coughing, laughing
 Effective Treatment: Kegel exercises
 Imagine Elevator: contract up to 10th floor (count to 10)
 Relax and lower to 1st floor (count to 10)
 Repeat 10 times in a row
 3-5 sets per day
 Urge Incontinence: incontinence after strong sense of urgency; may be in small or large amounts
 Effective Treatment: timed voiding (every 2 hours) and bladder retraining
 gradually postpone intervals between voiding to 4-6 hrs; stabilizes bladder
 Diversions
 Urinary Stoma
 Incontinent or continent
 Nephrostomy
 Tube placed in renal pelvis
 Nursing Assessment
 History:
 Voiding pattern (day and night, amount)
 Description of urine
 Any elimination symptoms, specifically:
 Frequency
 Urgency (difficulty getting to bathroom)
 Small amts or feeling of bladder fullness
 Dysuria (painful)
 Accidental leakage
 Men: hesitancy (difficulty starting stream)
 Hx of UTIs?
 Factors influencing Urinary Elimination: meds (espec diuretics), mobility and self-toileting status,
fluid intake, past illness and surgery, previous dx tests)
 Patient Expectations
 PE: Percussion for _______________ tenderness, palpation of bladder
 Assessing Urine
 Assessing Input/Output and 24 hr trend
 Assessing characteristics (color, clarity, odor, hematuria)
 Measuring urine
 Measure in calibrated container from hat, bedpan or catheter bag
 Normal = 60 ml/hr
 * REPORT * if less than 30 ml/hr
 Common Diagnostic tests:
 To check for UTI:
 urine dip or urinalysis (UA)
 Urine culture
 requires sterile/”Clean catch”
 Identifies # and type of bacteria as well as antibiotics to which it is susceptible and resistant
 24 hour urine sample
 Tests that evaluate kidney function:
 Serum Creatinine and BUN
 Interpreting Urinalysis (UA)
 Infection is indicated if:
 Presence of elevated WBC
 Presence of nitrite
 Presence of leukocyte esterase
 This is a performance standard for the course
 Common Nursing Diagnoses
 NANDA:
 Impaired Urinary Elimination
 Stress Urinary Incontinence
 Urge Urinary Incontinence
 Total urinary incontinence
 Urinary Retention
 Toileting self care deficit
 Nursing Diagnosis
 As Etiology of another issue:
 Risk for Infection R/T Urinary Incontinence
 Risk for Impaired Skin Integrity R/T Urinary Incontinence
 Knowledge Deficit R/T Prevention of UTI
 Risk for Caregiver Role Strain R/T Urinary Incontinence
 Social Isolation R/T Urinary Incontinence
 Goals
 Maintain or Restore Normal Voiding
 Regain Normal Urine Output
 Prevent Associated Risks: Infection, Skin Breakdown, Fluid/Electrolyte Imbalance, Decreased Self
Esteem
 Perform toileting activities independently with assistive devices
 Nursing Interventions
 Maintaining Normal Urinary Elimination
 Promoting Adequate Intake (________________cc/day)
 Contraindicated if CHF, Kidney Failure
 Maintaining Normal Voiding Habits
 Positioning
 Relaxation
 Timing

Promotion of Complete Emptying
 Drug Therapy
 Increase emptying (in retention): Urecholine (Bethanocol)
 Decrease hyperactivity of bladder (in urge incontinence) Tolterodine (Detrol), Oxybutinin
(Ditropan)
 Teaching: Preventing UTI:
 Drink 8 8-oz glasses of water/day
 Void frequently; do not “hold”
 Void after intercourse (*evidence-based)
 Avoid harsh soaps, bubble baths
 Increase acidity of urine (Vit C, cranberry juice)
 Wipe front to back
 Managing Urinary Incontinence
 Maintain Skin Integrity
 Skin that is continually moist becomes macerated; urine converted to ammonia: irritating
 After incontinence, wash thoroughly with soap and water; rinse, dry thoroughly and provide dry
clothing or linen
 Barrier creams (Zinc oxide)
 Absorbant draw sheets
 External Devices: condom, external catheter (not very effective)
 For Stress Incontinence: _______________ exercises
 For Urge Incontinence: Timed voiding or Bladder training
 Timed voiding has been found to significantly decrease patient falls in institutions
 Consider effect of socialization if living independently
 Managing Foley Catheterization
 40% of nosocomial infections are R/T Foleys
 Nursing Interventions to Prevent UTIs in patients with Foley Catheters
 Fluids: 3000cc/day if permitted
 Perineal care: no special cleansing necessary but cleanse thoroughly after BM
 Good handwashing when working with Foley and bag
 Maintain sterile closed-drainage system
 No need to change tubing: Do not disconnect tubing unless absolutely necessary
 Remove catheter as soon as possible to prevent nosocomial UTI
 Assessments:
 Monitor urine output: should be at least 60cc/hr
 If less: check placement
 If still no improvement call MD; could be clogged or could indicate serious condition
 Monitor color, clarity, odor of urine and mental status: at high risk for developing UTI
 Once Foley is removed, patient should void within 6-8 hours else requires urgent
assessments/interventions for urinary retention
 Evaluation
 Reassess voiding patterns and signs of alteration
 Inspect urine
 Expectations were met?
 Demonstrate self care skills