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PROMOTING URINARY ELIMINATION

OBJECTIVES

  • Review the structure and functions of the urinary system: Understanding the components and roles of the urinary system in maintaining homeostasis.
  • Determine abnormal appearance of a urine specimen: Identifying characteristics that deviate from normal physiology.
  • Describe three nursing measures to help patients urinate normally: Implementing strategies to facilitate urinary elimination.
  • Compare and contrast the purposes and principles of indwelling and intermittent catheterization: Evaluating different catheterization techniques based on patient needs.
  • Summarize the rationale for using a continuous bladder irrigation system: Understanding indications for continuous irrigation.
  • Analyze different methods of managing urinary incontinence: Identifying techniques for addressing incontinence in patients.
  • Assess a patient’s urinary status: Evaluating urinary function and needs.
  • Perform a urine dipstick test accurately: Using diagnostic tools to assess urine chemistry.
  • Teach a patient how to obtain a “clean-catch” (midstream) specimen: Guiding patients on proper sample collection techniques.
  • Assist patients with toileting: Supporting patients in their daily routines.
  • Insert an indwelling catheter using sterile technique: Following protocols for catheter insertion.
  • Perform catheter care: Ensuring the maintenance of catheter hygiene and functionality.
  • Teach a patient how to perform Kegel exercises: Educating patients on pelvic floor strengthening exercises.

STRUCTURE OF THE URINARY SYSTEM

  • Kidneys

    • Two bean-shaped organs
    • Dimensions: 2 ½ inches wide, 5 inches long, 1 inch thick
    • Positioned at the level of L1 on either side of the spine
    • Each kidney contains approximately 1 million nephrons.

  • Nephrons

    • Functional units of the kidney.
    • Composed of glomerulus surrounded by Bowman’s capsule and a system of tubules.

  • Ureters

    • Hollow tubes transporting urine from the kidneys to the bladder.
    • Length: 25 to 30 cm.

  • Bladder

    • Hollow muscular organ in the lower pelvis storing urine.

  • Urethra

    • Conveys urine from the bladder to the meatus; flow controlled by the urinary sphincter.
    • Meatus: Exit point for urine.

FUNCTION OF THE URINARY SYSTEM

  • Kidneys

    • Filter blood; remove metabolic waste and excess water.
    • Regulate electrolyte balance, maintain acid-base homeostasis by excreting excess hydrogen ions and retaining bicarbonate.
    • Urine production: approximately 1-1.5 L in 24 hours.

  • Ureters

    • Carry urine from kidneys to bladder.

  • Bladder

    • Stores urine, sends signals at fullness.
    • Voluntary control to empty when 250 to 400 mL is present.
    • Capacity: 1000-1800 mL; average output (UOP): 1000-1500 mL/day.

  • Urethra

    • Transports urine, sphincter control during micturition.
    • At least 600 mL of urine must be expelled daily to eliminate waste.

  • Urinary Meatus

    • Exit point for urination.

FACTORS INTERFERING WITH URINARY ELIMINATION

  • Total loss of kidney function.
  • Decreased kidney perfusion.
  • Ureteral blockage.
  • Bladder disruption due to tumors or trauma.
  • Enlarged prostate.
  • Infections.
  • Neurological damage to the nerves.
  • Prostate surgery.

CHANGES OCCURRING WITH AGING

  • Decrease in functioning nephrons.
  • Reduction in filtration rate.
  • Decreased bladder tone leading to nocturia.
  • Increased residual urine due to decreased bladder emptying.
  • Enlarged prostate causing urethral obstruction.
  • Incontinence is not a normal aspect of aging.
  • Low estrogen levels causing atrophy in urethra, vagina, and bladder.

NORMAL URINARY ELIMINATION

  • Infants: Void 5 to 40 times/day.
  • Preschool children: Typically void every 2 hours.
  • Adults: Voiding 5 to 10 times/day.
    • Males: Void 300 to 500 mL.
    • Females: Void 250 mL.
  • Average output: approximately 30 mL/hr.

FACTORS AFFECTING NORMAL URINATION

  • Neurological and muscle development.
  • Alterations in spinal cord integrity.
  • Fluid intake and loss (perspiration, vomiting, diarrhea).
  • Antidiuretic hormone (ADH) secretion by the pituitary gland.

CHARACTERISTICS OF NORMAL URINE

  • Color: Straw-colored or amber.
  • Clarity: Transparent or slightly cloudy.
  • Odor: Faint ammonia smell.
  • Specific Gravity: Normal range is 1.010 to 1.030.
  • pH: Slightly acidic (5.5 to 7.0).

ALTERATIONS IN URINARY ELIMINATION PATTERNS

  • Anuria: Less than 100 mL of urine output in 24 hours.
  • Dysuria: Painful or difficult urination due to infection or trauma.
  • Incontinence: Involuntary urine release.
  • Nocturia: Frequent nighttime urination (more than twice).
  • Oliguria: Decreased urine output (< 400 mL in 24 hours).
  • Polyuria: Excessive urination (> 1500 mL in 24 hours).

CYSTITIS

  • Inflammation of the bladder.
    • Causes: Irritation from concentrated urine, bacteria, injury, or irritating substances.
    • Symptoms: Frequency, urgency, dysuria, burning sensation, suprapubic pain, malaise, foul-smelling urine, slight fever.

PREVENTION OF RECURRENT CYSTITIS

  • Increase fluid intake: 2500-3000 mL/day.
  • Avoid citrus fruits and juices, which may cause alkaline urine fostering bacteria growth.
  • Wipe from front to back after bowel movement.
  • Avoid tight clothing and nylon fabrics.
  • Prevent prolonged wetness (e.g., bathing suits).
  • Refrain from bubble baths or feminine hygiene sprays.
  • Empty bladder promptly post-intercourse and drink two glasses of water afterward.
  • Maintain daily bathing and regular bladder emptying every 2-3 hours to prevent stasis.

ASSESSMENT OF URINARY FUNCTION

  • Assess patients for:
    • Usual elimination patterns.
    • Incidents of incontinence or frequent urination.
    • Burning sensation during urination.
    • Sense of urgency.
    • Nighttime urination.
    • Total daily fluid intake.

URINE SPECIMENS

  • Normal voided specimen: Send to the lab within 5 to 10 minutes; changes occur after 15 minutes.
  • Midstream (clean-catch) specimen: A technique for urine collection.
  • Indwelling catheter specimen: Obtained from an indwelling catheter.
  • Sterile catheterized specimen.
  • 24-hour specimen: Collected over 24 hours.
  • Urinary collection bag: Used in specific assessments.
  • Strained specimen: To catch stones or debris.

ABNORMALITIES FOUND IN URINE

  • Glycosuria: Presence of glucose in urine, potentially indicative of diabetes.
  • Proteinuria: Presence of protein in urine, suggesting kidney impairment.
  • Hematuria: Blood in urine, indicating stones, tumors, or bleeding disorders.
  • Pyuria: Presence of pus in urine, usually indicating infection.
  • Ketonuria: Presence of ketones in urine, indicating fat metabolism.
  • Red Blood Cells: Count >0-2 could signify underlying conditions.
  • White Blood Cells: Elevated levels suggesting infection or inflammatory processes.
  • Bilirubin: May indicate liver disease or bile duct obstruction.

NURSING DIAGNOSIS

  • Potential diagnoses include:
    • Altered urinary function.
    • Urinary retention.
    • Incontinence.
    • Altered body image.
    • Potential for infection.
    • Acute pain or chronic pain.
    • Potential for injury (to kidneys from urine blockage).
    • Altered self-care abilities.
    • Potential for compromised skin integrity.
    • Insufficient knowledge regarding urinary health.

PLANNING FOR PATIENT CARE

  • Increase fluid intake.
  • Reinforce education on UTI prevention.
  • Inform patients about urine specimen collection needs.
  • Be culturally sensitive in care approaches.
  • Monitor urinary retention by recording each void's amount and palpating the bladder for distention.
  • Provide assistive devices as necessary (e.g., grab bars, bedside commode).
  • Recognize that catheterization may affect body image, even short-term.

ASSISTIVE DEVICES

  • Options for aiding in toileting:
    • Toilet.
    • Commode chair.
    • Raised toilet seat.
    • Bedpan.
    • Fracture pan.
    • Urinal.
    • "Hat" (urine collection device).
    • Various types of catheters (indwelling, intermittent).

INITIATE VOIDING STRATEGIES

  • Suggestions to promote urination:
    • Run water in a sink nearby.
    • Encourage deep breathing and visualization.
    • Offer warm caffeinated beverages.
    • Assist males standing at bedside; suggest females use a straw in water.
    • Pour warm water over the perineum (subtracting the amount from total volume for accurate measurement).
    • Employ the Crede maneuver under orders for bladder stimulation.
    • Sitz bath for increased comfort.
    • If unable to void for >8 hours, utilize a bladder scanner and consider catheterization if needed.

REASONS FOR CATHETERIZATION

  • Indications include:
    • Pre-surgical or obstetric preparation.
    • Post-surgical genital and perineal hygiene.
    • Urethral stricture dilation.
    • Urethral splinting post-surgery.
    • Measuring residual urine.
    • Monitoring UOP or total output.
    • Bladder irrigation or instillation for treatment.
    • Assisting bladder toning post-surgery.

TYPES OF URINARY CATHETERS/SPECIMENS

  • Catheter types:
    • Robinson, Foley, Suprapubic, Coudé, Alcock, De Pezzer, Malecot, Condom catheters.

PERFORMING CATHETERIZATION

  • Sterile technique is paramount.
  • Always correct aseptic breaks before proceeding.
  • Similar procedure for male and female catheterization with variations in positioning.
  • Insertion guideline: insert until urine flow begins, then advance 1-2 more inches.

CARE OF INDWELLING URINARY CATHETER

  • Ensure adequate fluid intake by the patient.
  • Maintain a closed drainage system.
  • Measure and record UOP every 8 hours.
  • Hand hygiene before/after catheter handling; use clean gloves.
  • Empty urine bags properly and observe drainage status regularly.
  • Prevent tubing kinks; check for bladder distention and proper positioning.
  • Perform peri-care at least twice daily, cleaning catheter as per protocol.
  • Ensure catheter attachment prevents pulling and maintain proper cleaning routines.
  • Anticipate a minimum of 30 mL/hr UOP; investigate if UOP falls below this threshold.

PREVENTING CAUTI (Catheter-Associated Urinary Tract Infections)

  • Significant contributor to hospital-acquired infections (30% of cases).
  • Basic infection control measures: hand hygiene, proper catheter use, alternatives where possible.
  • Checklist for catheter necessity and duration of placement.

BLADDER IRRIGATION OR INSTILLATION

  • Purpose: Cleans bladder of residual urine/sediment.
  • Indications include:
    • Removal of clots, control of bleeding post-surgery.
    • Promoting healing of irritated tissues.
    • Medication instillation.
  • Important to maintain sterility of equipment and techniques during procedures.

INCONTINENCE

  • Types include:
    • Urgency, stress, overflow, functional, mixed, nocturnal enuresis.
  • Results in loss of normal bladder control, which can lead to:
    • Body image disturbances, increased risk of skin integrity impairment, risk of infection.
  • Interventions may include surgical options and Kegel exercises.

KEGEL EXERCISES

  • Recommended frequency: 3 times daily or as ordered.
  • Technique: Squeeze pelvic muscles for 10 seconds, relax for 10 seconds, focus on stopping urine flow during voiding (avoid contracting abdominal muscles).
  • Avoid breath-holding during contractions.

URINARY DIVERSION CARE

  • Necessary when the bladder is removed or bypassed.
  • Options for ureter implantation include:
    • Urostomy: implanting ureters into abdominal wall.
    • Bowel or pouch construction for urine collection via catheter.
  • Skin care is specialized based on diversion type.

EVALUATION

  • Look for:
    • Ability to urinate without urgency, dysuria, frequency.
    • Evaluate urine analysis for signs of infection resolution.
    • I&O documentation to assess fluid balance.
    • Perineal skin condition in incontinent patients to ensure protective measures are effective.
    • Reduction in incontinence episodes as an indication of training program effectiveness.
    • Patient and family understanding of catheter care and drainage system management.

DOCUMENTATION

  • Essential documentation includes:
    • Normal voiding patterns and quantities.
    • Complaints related to voiding (e.g., dysuria).
    • Continence status.
    • Quantitative output records.
    • Records of bladder irrigations and catheter management (inserted or removed).

KEY POINTS

  • The urinary system (kidneys, ureters, bladder, urethra) is essential for waste and fluid elimination, with kidneys managing fluid balance.
  • Conditions such as infection, dehydration, and obstruction can impede urinary function.
  • Age-related changes include decreased kidney function and bladder tone, with risks of urethral obstruction in males due to prostate enlargement.
  • Normal urination frequency for adults is 5 to 10 times daily, averaging 1 to 1.5 L of urine.
  • Urinary dysfunction symptoms include urgency, dysuria, and changes in output volume.
  • Urine specimens should be collected using appropriate techniques for accurate diagnostic results.
  • Indwelling catheters are indicated for various clinical scenarios and require strict adherence to sterile procedures.
  • Closed intermittent irrigation is the preferred method to reduce infection risks.
  • Various types of incontinence exist, each necessitating tailored interventions, and skin care is essential for patients with urinary diversions.
  • Daily comparison of intake and output is critical in evaluating patient status and urinary function.