NURS 305 - Ch 46 Urinary Elimination

urinary elimination

• basic human fxn 

  • many things can interrupt 

  • last step in H2O & waste product removal 

urinary system

• kidneys

• ureters

• bladder

• urethra

kidneys

• bean shaped

• maintain balance of minerals & H2O in body 

• regular BP (RAS system) 

• filter & cleanse blood

• synthesize hormones that convert vit D to active form 

• erythropoietin 

erythropoetin

• signals RBC production in bone marrow 

kidney flow

• blood goes thru nephrons → glomerulus (in nephron, in cortex) → bowman’s capsule → medulla → collecting ducts → ureters 

urethra

• females: 3-4cm

  • higher UTI risk - close to anus

• males: 18-20cm

micturition

• dependent on brain signals, bladder contraction, & sphincter relaxation 

• should put out 1-2L of urine a day! 

  • 30mL/hr 

  • increases/decreases indicate problem 

factors influencing urination

• physiological

• psychosocial

• diagnostic/treatment related 

common urinary elimination issues

• storing/emptying

  • retention

  • UTIs

  • incontinence 

  • diversions

  • CAUTI

  • bacteriuria 

  • pyelonephritis

  • cystitis

urinary retention

• inability to empty bladder partially or completely 

• pressure, pain, no peeing, frequency/urgency

• can feel it!

• bladder scan or straight cath to determine post residual vol 

urinary tract infections

• UTIs

• 5th most common HAI 

  • bc of catheters 

• categorized by location 

• symptoms indicative of infection

urinary incontinence

• involuntary loss of urine

types of incontinence

• transient

• functional

• assocaited w/ chronic retention

• stress

• urge/urgency

• reflex

transient incontinence

• caused by medical conditions

  • usually treatable & reversible

transient incontinence characteristics

• delirium/confusion

• inflammation 

• excessive urine output 

• mobility impairment

• fecal impaction 

• depression 

• acute urinary retention 

fxnal incontinence

• bc of causes outside of urinary tract

• fxnal deficits 

  • mobility/dexterity issues, cognitive impairment, poor motivation, environmental barriers

• caregivers not responding in time

incontinence associated w/ chronic retention

• involuntary loss of urine bc of overdistended bladder

  • related to bladder outlet obstruction/incomplete bladder emptying bc of weak/absent contractions

incontinence associated w/ chronic retention characteristics

• distended bladder on palpation

• high postvoid residual 

• frequency

• involuntary small vol leakage 

• nocturia 

stress incontinence

• associated w/ increased intraabdominal pressure

  • related to urethral hypermobility/incompetent sphincter 

• bc of weakness/injury to sphincter/pelvic floor 

• urethra cannot stay closed during bladder pressure increases bc of increased abdominal pressure 

stress incontinence characteristics

• small vol loss w/ coughing, laughing, exercise, walking, getting up 

• usually doesn’t leak at night 

urge/urgency incontinence

• associated w/ strong sense or urgency r/t overactive bladder from neurological problems, bladder inflammation, or outlet obstruction 

• idiopathic a lot of the time 

• involuntary contractions of bladder associated w/ urge to void that causes leakage

urge/urgency incontinence characteristics

• urgency

• frequency

• nocturia

• inability to hold urine once urge appears

• leaks otw to bathroom 

• leaking large amts 

• strong urge to urinate w/ running water or drinking fluids 

reflex incontinence

• somewhat predictable intervals 

  • when pt reaches bladder vol related to spinal cord damage btwn C1 & S2

reflex incontinence characteristics

• diminished/absent awareness of bladder filling & void urge 

• leaking w/o awareness 

• many not completely empty bladder bc of lack of sphincter sensation → contracting when bladder contracts → obstruction 

• at risk of autonomic dysreflexia! 

  • severe BP elevation 

transient incontinence interventions

• w/ new/increased incontinence, look for reversible causes

• let provider know of any suspected reversible causes

fxnal incontinence interventions

• adequate bathroom lighting 

• individualized toileting program 

• mobility aides

• toilet area cleared to allow access for aides 

• elastic waist pants 

• nurse call system within reach 

• use of incontinence containment products 

chronic retention incontinence interventions

• related to severity! 

• mild

  • timed/double voiding

  • monitor postvoid rediual 

  • intermittent catheterization

• severe

  • catheters 

stress incontinence interventions

• pelvic floor exercises 

  • kegels 

urge/urgency incontinence interventions

• ask abt UTI symptoms

• avoid bladder irritants

• pelvic floor exercises

• bladder training 

• monitor for symptoms & side effects of antimascarinic meds 

reflex incontinence interventions

• follow schedule to empty! 

  • intermittent catheterization 

• supply urine containment products 

• monitor for signs & symptoms of UTIs

• monitor for autonomic dysreflexia

urinay diversions

• temporary/permanent

  • continent

  • incontinent

continent urinary diversions

• no leaking!

  • continent urinary reservoir 

  • orthotopic urinary bladder 

• pt has to willingly cath self thru stoma 4-6x a day

incontinent urinary diversions

• urostomy

  • stoma

  • has collection bag

• nephrostomy

  • tube 

CAUTI

• catheter associated urinary tract infection 

• very costly 

• preventable 

• 12-16% of adult hospital in pts will have a catheter at some point 

• Each day pt has one in, risk increases by 3-7%

bacteriuria

• bacteria in urine

  • can be asymptomatic 

    • don’t do anything!

pyelonephritis

• upper urinary tract infection - kidneys! 

• back/flank pain 

  • fever, nausea, vomiting 

• antibiotics need

lower UTI

• burning/pain w/ urination 

• cloudy urine w/ foul smell 

cystitis

• bladder irritation/inflammation

  • urgency

  • frequency

  • incontinence 

infection control/hygiene

• urinary tract sterile - keep it that way !

  • wipe front → back

    • use clean technique w/ just cleaning

  • sterile technique w/ cathing

    • any insertion really

growth & development

• micturition control changes through life

  • develops void urge understanding at 2/3

• older adults at risk of complications w/ changes

psychosocial implications

• affect

  • self-concept

    • hard w/ incontinence

  • culture

    • some ppl private, some don’t care

  • sexuality 

    • urinary diversions & body image issues

sucessful critical thinking requires

• knowledge

• experience

  • personally & professionally

• info gathered from pts

  • subjective & objective

• critical thinking attitudes 

• intellectual & professional standards

• reflection on personal experiences

critical thinking attitudes

• perservere!

• think through things 

• be creative 

assessment

• through pt eyes

• self-care ability

• cultural considerations

• environmental factors

• nursing history

through pts eyes

• each person diff! 

• understanding/expectations 

• privacy physically & verbally 

• be open & honest 

• answer Qs

• educate on IV fluids 

self-care ability

• what can pt do? 

• strength & coordination? 

• cognitive deficit?

cultural considerations

• acceptable to pt?

• be sensitive & straightforward

  • ie: males caring for females 

envrionmental factors

• assistive devices? 

• bedpans?

nursing history

• pattern of urination 

• symptoms of urinary alterations

  • use layman’s terms

physical assessment

• kidneys

• bladder

• external genetalia & urethal meatus 

• perineal skin

kidney physical examination

• look for flank/back pain

• assess CVA tenderness 

  • back tenderness

bladder physical examination

• can palpate when full above pubic symphysis @ midkine 

• when rlly bad, can extend up to umbilicus

  • urge, tenderness, pain 

external genetalia & urethra meatus physical examination

• careful & sensitive inspection

• female: dorsal recumbent 

  • frog legs

• male: retract foreskin 

  • look for swelling, tenderness. rash, discharge 

perineal skin physical examination

• skin breakdown!

  • esp w/ incontinence/catheters

• increased mositure, increased UTI risk

urine assessment

• intake & output

  • count void # - should be ~5 a day 

• characteristics 

• gives bladder fxn insight, renal fxn, fluid & electrolyte balance 

intake & output

• strict orders sometimes! 

• food, fluids, stool, emesis, meds, wound discharge 

urine characteristics

• color

  • pale straw → amber 

    • concentration!

• clarity - no sediment/cloudiness 

• odor - ammonia

labs & diagnostic tests

• nurses collect

• UA - urinalysis 

routine urinalysis

• screening & diagnostics for fluid & electrolyte imbalances, UTI, presence of blood, etc 

• collect during normal voiding 

• might need to test w/ reagent strips 

urinalysis findings

• pH

• protein

• glucose

• ketones

• specific gravity

• RBCs

• WBCs

• bacteria

• casts

• crystals 

urine pH

• 4.6-8.0

• indicates acid-base balance

  • acid protects against bacterial growth 

• standing urine can become alkaline 

urine protein

• up to 8mg/100mL 

• usually not present 

  • damage to glomerular membrane - larger particles can pass thru

urine glucose

• not normally present

• poorly managed diabetes 

  • tubules can’t resorb high glucose concentrations 

• LARGE sugar ingestion 

urine ketones

• not normally present

• poor T1D management 

  • breakdown of fatty acids 

• dehydration, starvation, excessive aspirin 

urine specific gravity

• 1.005-1.030

• concentration of particles in urine 

  • high - concentrated 

    • dehydration, reduced renal blood flow, increased ADH

  • low - diluted 

    • overhydration, renal disease, inadequate ADH

urine RBCs

• up to 2 

• damage to glomeruli/tubules 

• trauma, disease, catheters, surgery to lower urinary tract

urine WBCs

• 0-4

• indicate inflamation/infection

urine casts

• cylindrical bodies

• hyaline, RBCs, WBCs, granular cells, epithelial cells

• indicate renal disease

urine crystals

• not normally present

• indicate risk for kidney stones 

• high uric acid lvls (gout)

nursing diagnosis ex

• look at individual pt! prob for one might not be for another

  • incontinence of urine: fxnal, overflow, reflex, stress, urge

  • urinary tract infection

  • impaired self toileting 

  • impaired skin integrity 

  • urinary retention 

impaired skin integrity

• r/t excess moisture & immobilty AEB warm temp, skin erosion, erythema

urinary elimination priorities

• address immediate physical & safety needs 

• expectations & readiness to perform self care 

• BOGO deals! 

health promotion

• help pt understand & participate in self care practices

• preserve & protect genitourinary system fxn 

  • education

  • promoting normal micturition

  • maintaining adequate fluid intake

  • promoting complete bladder emptying

  • preventing infection

pt education

• best & most effective!

• overcome & prevent issues

• focus on prob itself

  • ie: UTI & wiping fron tto back, no caffiene, no tight clothes, etc

promoting normal micturition 

• maintaining elimination habits

  • keep routines as much as possible 

  • privacy 

  • be present for them 

• fluid intake!

maintaining fluid intake

• helps w/ peeing 

• should be 2300mL/day 

  • helps flush 

  • lowers bladder irrigation 

promoting complete bladder emptying

• none? increased incontinence, UTI, kidney damage risk 

  • not coming out ? backs up 

• assume normal position ! 

  • sit/stand up 

• run sink water

• do kegels

• attempting 2nd void

• toileting schedules

preventing infection

• fluid intake 

• front - to - back wiping 

• retracting foreskin 

• voiding at regular intervals 

  • esp after sex 

catheterization

• big source of infection 

• do sterile! 

types of catheter

• straight/intermittent

  • one & done 

• indwelling 

  • double & triple lumen 

triple lumen catheter

• for meds & bladder irrigation 

• larger balloon - 30mL

catheter sizes

• many! 

• adult: 14fr-16fr 

  • smaller for smaller ppl

  • bigger for ppl w/ lots of clots

catheter changes

• try to minimize

  • go on as long as possible w/ care! 

• long term use → change every 4-6wks 

closed drainage systems

• interdwelling 

• never separate parts! 

  • pathogens can enter

routine catheter care

• prevents infection 

  • esp w/ stool incontinence 

• wiping w/ what & how often? 

• hospital policies 

  • by book - every 8hrs 

• don’t wait till full to empty - aim for ½ ! 

• pay attention to actual drainage rate 

preventing catheter-associated infection

1. sterile technique w/ insertion

2. closed drainage systems 

3. keeping below bladder (anti-reflux)

4. no dependent loops

5. Using alternative drainage devices 

6. Prevention checklists & eval of catheter indications 

7. Using smallest catheter possible for pt 

8. Remove ASAP

9. Secure indwelling catheters to prevent movement & pulling 

10. Maintaining unobstructed flow of urine thru catheter, drainage tubing, & drainage bag 

11. Use separate measuring receptacle ofr each pt. Don’t let spigot touch receptacle for

12. Use quality improvement/survillance programs

13. Perform routine peri care daily & after soiling

catheter irrigation & installation

• post op, clears clots, meds given sometimes 

  • keep system closed

removal of indwelling catheter

• ASAP 

  • increased infection risk, CAUTIs

• use clean technique

• watch output for 48hrs 

  • should void within 6 

    • might hurt/burn at first 

alternative to urethral catheterization

• last resort 

• not done for incontinence except for crazy wounds 

  • suprapubic catheterization 

  • external catheter

suprapubic catheterization

• surgical! 

• abdomen → bladder 

• secured within 

• for urethral blockages 

external catheters

• least invasive 

• collection device 

  • males - condom caths & male purewicks

  • females - purewicks

urinary diversion state

• stomas! 

  • pink

  • moist

  • skin intact 

• pouched

• changed every 4-6 days 

• no skin exposure!

• 4×4 gauze wick!

urinary system meds

• anti-muscarinics: help w/ urgency 

• antibiotics for infection

restorative care interventions

• lifestyle changes

• pelvic floor training

• bladder retraining

• toileting schedules 

• intermittent catheterizaiton

lifestyle changes

• avoiding bladder irritating food/fluids 

  • don’t overdo fluids 

  • artificial sweeteners, spicy food, citrus, caffeine 

pelvic floor muscle training

• kegels

  • have pt squeeze anus as if holding in gas 

    • insert finger into vagina and feel muscle squeeze 

    • see if penis moves up & down 

  • don’t contract abdomen, buttocks, or thighs 

• 3-5 quick flicks then 10 sustained contractions 

• 3-4x a day 

bladder retraining

• behavioral

• given schedule!

  • based on urinary diary & leaking 

toileting scheduels

• fixed 

• voiding when there is no urge to void 

• 2-3hr intervals 

intermittent catheterization

• neuromuscular damage 

• diabetes 

• spinal cord issues 

• skin care must be done - bc of leaks 

strengthening of pelvic floor muscles

• strength → increased urethral pressure → can withstand contraction of bladder