Chapter 45: Urinary
Elimination
Bonnie M. Wivell, MS, RN, CNS
Anatomy
• Kidneys remove wastes from the blood to form
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urine; play a key role in fluid and electrolyte
balance
Ureters transport urine from the kidneys to the
bladder
The bladder holds urine until the urge to
urinate develops
Urine leaves the body through the urethra
Nephron is working unit of kidney; forms urine;
contains glomerulus surrounded by Bowman’s
capsule
– Bowman’s capsule, proximal convoluted tubule, loop
of Henle, distal tubule, collecting duct
Kidney
Filtration
• Filtration of H2O, glucose, amino acids, urea,
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creatinine, and major electrolytes into Bowman’s
capsule
Large proteins and blood cells do not normally
filter through the glomerulus
Proteinuria = the presences of large proteins in
the urine; a sign of glomerular injury
Glomerulus filters approximately 125 mL of
filtrate per minute
The Kidneys
• Normal adult urine output is 1500 to 1600
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mL/day
An output of < 30 mL/hr indicates possible renal
alteration
Kidneys produce several substances vital to
production of RBC, BP, and bone mineralization
Produces erythropoietin which stimulates RBC
production and maturation and prolongs the life
of the mature RBCs
– Patients with chronic alterations in kidney function
cannot produce sufficient quantities of this hormone
therefore they are prone to anemia
The Kidneys Cont’d.
• Renal hormones affect BP regulation in several
ways
– Renin and angiotensin I and II cause vasoconstriction
– Aldosterone released resulting in water retention
– Prostaglandin – maintains renal blood flow via
vasodilation
• Affect calcium and phosphate regulation by
producing a substance that converts vit D into
its active form
– Renal bone disease results from demineralization of
the bone cause by impaired calcium absorption
Act of Urination “Micturition”
• Brain structures that influence bladder
emptying
– Cerebral cortex, Thalamus, Hypothalamus,
Brain Stem
• Normal voiding involves contraction of the
bladder muscles and coordinated
relaxation of the urethral sphincter and
pelvic floor muscles
Act of Urination Cont’d.
• Factors influencing urination
– Amount of urine in the bladder
• Adult normally holds 600mL
• Child 150 – 200mL
– Increasing urine volume stimulates the
micturition center in the sacral spinal cord
– Normally voiding is a voluntary process
Factors Influencing Urination
• Disease Conditions
– Prerenal: decreased blood flow to and
through the kidneys
– Renal: disease conditions of the renal
tissue
– Postrenal: obstruction in the lower
urinary tract that prevents urine flow
from the kidneys
Diseases That Influence Urination
• Diabetes
• Multiple Sclerosis
• BPH – Benign Prostatic Hyperplasia
• Cognitive Disorders
– Alzheimer’s Disease
• End-Stage Renal Disease
– Requires dialysis
Other Factors That Influence
Urination
• Socio-cultural Factors
– Privacy
• Psychological Factors
– Anxiety
• Fluid balance
• Surgical procedures
• Medications
• Diagnostic examination
Terminology to Know
• NOCTURIA
• POLYURIA
• OLIGURIA
• DYSURIA
• ANURIA
• DIURESIS
• CYSTITIS
• HEMATURIA
• PYLONEPHRITIS
• INCONTINENCE
• NOCTURNAL
ENURESIS
Alterations in Urinary Elimination
• Urinary Retention
– Accumulation of urine resulting from an inability of
the bladder to empty properly
• Bladder unable to respond to the micturition reflex
• Possible Causes
– Urethral obstruction
• Surgical trauma
• Child birth
• Alterations in sensory innervation
• Anxiety
• Side effects of medications
Alterations in Urinary Elimination
• Urinary tract infections (UTIs)
– Most common healthcare associated infection
• Catheterization
• Surgical Manipulation
• 75% – 95% Caused by E-Coli
• Any condition resulting in urinary retention
(Kinked, obstructed or clamped catheter)
increases the risk of bladder infection
Alterations in Urinary Elimination
• Urinary Incontinence
– Involuntary urination
• Causes
– Aging
• 50% of all LTC residents suffer from incontinence
• Complications
– Skin breakdown
Alterations in Urinary Elimination
• Urinary Diversion
– Divert ureters to abdominal wall stoma
– Causes
• Cancer of the bladder
• Trauma
• Radiation
• Chronic cystitis
– Nephrostomy – drainage via tube placed
directly into the renal pelvis
Ileal Conduit
Nephrostomy
Normal vs Abnormal Urine
• NORMAL URINE VALUES
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APPEARANCE: Clear
COLOR: Amber yellow
ODOR: Slight ammonia
pH: 4.6 – 8.0
PROTEIN: 0 – 8mg/dl
SPECIFIC GRAVITY: 1.005 – 1.030
LEUKOCYTES: Neg
NITRITES: Neg
KETONES: Neg
CRYSTALS: Neg
GLUCOSE: Neg
RBC: Neg
WBC: Neg
Normal vs Abnormal Urine
• Abnormal Findings
– Increased pH
• Respiratory or metabolic alkalosis
• Gastric suctioning
• Vomiting
• UTI
– Decreased pH
• Metabolic acidosis
• Diabetes
• Diarrhea
• Respiratory acidosis
Normal vs Abnormal Urine
– Increased protein
• DM
• CHF
• Pre-eclampsia
• Glomerulonephritis
• Polycystic disease
– Decreased protein
• Lupus
• Heavy-metal poisoning
• Bladder tumor
Normal vs Abnormal Urine
– Increased Specific Gravity
• Dehydration
• Glycosuria, proteinuria
• Fever
• Vomiting
• Diarrhea
– Decreased Specific Gravity
• Over-hydration
• Renal failure
• Hypothermia
• Pyelonephritis
Normal vs Abnormal Urine
– Increased RBCs
• Glomerulonephritis
• Acute tubular necrosis
• Cystitis
• Traumatic catheterization
– Increased WBCs
• Bacterial infection in the urinary tract
• Glomerulonephritis
• Acute pyelonephritis
• Lupus
Infection Control and Hygiene
• The urinary tract is a sterile environment
– Apply knowledge of medical and surgical
asepsis when providing care involving the
urinary tract
– Catheterization is a sterile technique
– Perineal care and catheter care is a clean
procedure
Psychosocial Considerations
• Gender differences
– Males stand to urinate
– Females sit to urinate
• How many people lie down to urinate??
Nursing Process and Alterations in
Urinary Function
• Assessment
– Subjective Information
• DIFFICULTY URINATING?
• PAINFUL URINATION?
• INCONTINENCE?
• FREQUENCY?
• URGENCY?
• LEAKING?
Nursing Process and Alterations in
Urinary Function
• Assessment
– Objective data
• Assess Urine: color, odor, amount
• Review lab data
• See Box 45-3 (page 1137) for assessment
questions
– Physical assessment
• Abdominal distention
Common Urinary Alterations
• URGENCY
• FREQUENCY
• HESITANCY
• RETENTION
• DRIBBLING
• INCONTINENCE
• RESIDUAL URINE
Diagnostic Examinations of the
Urinary System
• OBTAINING A URINE SPECIMEN
– RANDOM
– CLEAN CATCH (MIDSTREAM)
– STERILE
– TIMED COLLECTION
Diagnostic Examinations of the Urinary
System
• TESTING THE URINE
– CHEMICAL REAGENT STRIP (DIP STICK)
• BEDSIDE URINALYSIS
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pH
GLUCOSE
BLOOD
KETONES
PROTEIN
Diagnostic Examinations of the
Urinary System
• Testing the urine
– Sterile specimen
• Straight cath
• Aspiration from indwelling catheter
• Same procedure from urinary diversion
– Timed specimen to be sent to lab
• EXAMPLE: 24-HrUrine for UUN (Urine Urea
Nitrogen)
– Special container/Preservative
– MUST SAVE ALL URINE OR START OVER
– Ice
Nursing Implications
Diagnostic Examinations of the Urinary
System
• Clean catch or midstream
– Assemble equipment and instruct pt. on
technique to obtain specimen
• Straight Cath (in and out cath)
– Assemble equipment
– Explain procedure to pt.
– Insert catheter using sterile technique
– Send specimen to lab in sterile container
Nursing Implications
Diagnostic Examinations of the Urinary
System
• Obtaining sterile specimen from existing
urinary catheter
– Catheter must be clamped for about 30 mins
prior to aspiration
– Using a syringe and large bore needle, access
the collection port on the catheter tubing and
withdraw 5-10 mL of urine to send to lab
Nursing Implications
Diagnostic Examinations of the Urinary
System
• Non-Invasive examination of the bladder
and kidneys
– X-RAY: KUB = kidneys, ureters, bladder
• Simple film, no prep needed
• Determines size, shape, location and symmetry
– CT Scan
• Detailed images of structures. Tumors and
obstructions may be visible
• Prep: NPO, varies
• Determine patient allergy to iodine (injected during
procedure)
Nursing Implications
Diagnostic Examinations of the Urinary
System
– IVP: Intravenous Pyelogram
• Views collecting ducts, renal pelvis, ureters,
bladder and urethra
• Prep: Bowel cleansing
– Assess pt’s allergy to iodine and/or shellfish
• Post-test encourage fluids to flush dye from
system
– Monitor for delayed allergic reaction
Nursing Implications
Diagnostic Examinations of the Urinary
System
– Ultrasound of the bladder
• Identifies gross renal structures and
structural abnormalities
• No prep required
• Simple US (bladder scan) can be done on
the nursing unit to evaluate retained urine
(post-void residual – PVR)
Nursing Implications
Diagnostic Examinations of the Urinary
System
• Invasive Examination of the kidneys and
bladder
– Cystoscopy
• Direct visualization of the bladder and urethra
– Specimen collection
– Done using conscious sedation
• Post-Procedure
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Vital signs
I&O
Describe urine
Encourage fluids
Nursing Interventions that Promote
Normal Urination
• Intake and Output
– INTAKE: monitoring and measuring all liquid taken in
• Oral fluids
• IV fluids
– OUTPUT: measure all fluids eliminated from the body
• Urine
• Wound drainage
• NG drainage
• Diarrhea
Catheter Insertion
Male and Female
• Requires a provider order
• Explain procedure to patient
• Assemble equipment
• Assess patient
– Do you need help?
– Is the female patient able to maintain
lithotomy position?
– Is your female patient obese?
Suprapubic Catheters
• Surgical placement of a catheter through
the abdominal wall above the symphysis
pubis into the bladder
– Appropriate for use in paraplegic,
quadraplegic and comatose patients
– Slightly less chance for infection over the long
term
Condom Catheters
• For male patients only
• Alternative to catheterization
• Latex or silicone sheath that fits on penis
Catheter Irrigation/Instillation
• Irrigation
– Intermittent
– Continuous (CBI)
– PRN
• Instillation
– Medication
• Antiseptic
• Antibiotic
• Chemotherapy
Open Catheter Irrigation
• Clean gloves
• Sterile procedure
• Instill normal saline into bladder using a
50 mL catheter tip syringe
• Catheter, syringe, and irrigant must be
sterile
Closed Catheter Irrigation
• Catheter has 3 lumens
– Irrigant, Drainage, Balloon
• Calculating urine output
– Add total amount of irrigant instilled
– Add the total amount of urine plus irrigant
drained out
– The difference is urine output
Nursing Diagnosis
• Functional urinary incontinence
• Reflex Urinary incontinence
• Stress Urinary incontinence
• Total Urinary incontinence
• Urge Urinary incontinence
• Overflow Urinary incontinence
• Urinary Retention
• Risk for infection
• Risk for impaired skin integrity