Ch. 46 Urinary Elimination

Chapter 46: Urinary Elimination

Page 1: Overview of Urinary Elimination

• Introduction to urinary elimination and its significance in human physiology.

Page 2: Scientific Knowledge Base

• Basics of urinary elimination, foundational anatomy, and physiological processes related to urine production and excretion.

Page 3: Anatomy of the Urinary System

The urinary system consists of four main organs responsible for urine formation, storage, and elimination:

1. Kidneys

• Filter waste products and excess fluids from the blood.

• Regulate electrolytes, acid-base balance, and blood pressure.

• Produce erythropoietin, which stimulates red blood cell production.

2. Ureters

• Thin tubes that transport urine from the kidneys to the bladder.

• Prevent backflow of urine through peristalsis (wave-like muscle contractions).

3. Bladder

• A muscular sac that stores urine until elimination.

• Expands when filling with urine and signals the brain when it’s time to void.

4. Urethra

• A tube that carries urine from the bladder to the outside of the body.

• Male urethra: Longer (also transports semen).

• Female urethra: Shorter (higher risk of UTIs due to bacteria entering easily).

Page 4: Urination Basics

Urination (also called micturition) is the process of expelling urine from the bladder through the urethra.

Key Factors Influencing Urination (See Box 46.1 for more details)

• Age:

  • Infants and young children may have involuntary urination.

  • Older adults may experience decreased bladder control.

• Fluid intake:

  • More fluid → increased urination.

  • Less fluid → concentrated urine, risk of UTIs.

• Medications:

  • Diuretics increase urination.

  • Some medications may cause urinary retention.

• Psychological factors:

  • Anxiety and stress can affect urination habits.

• Muscle tone:

  • Weak pelvic muscles can cause urinary incontinence.

Common Urinary Elimination Problems

1. Urinary Retention:

   • Inability to completely empty the bladder.

   • Causes: Blockage, weak bladder muscles, or nerve issues.

2. Urinary Tract Infections (UTIs):

   • Bacterial infection in the urinary system (more common in women).

   • Symptoms: Burning sensation, frequent urination, cloudy urine.

3. Urinary Incontinence: (See Table 46.1 for types)

   • Stress incontinence: Leakage with sneezing, coughing, or laughing.

   • Urge incontinence: Sudden, intense need to urinate.

   • Overflow incontinence: Bladder does not empty completely.

   • Functional incontinence: Physical or mental barriers prevent reaching the toilet in time.

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4. Urinary Diversions:

   • Surgical procedure that redirects urine flow due to bladder removal or damage.

   • Types include urostomy and neobladder.

Page 5: Nursing Knowledge Base

This section covers important nursing considerations related to urinary elimination, including infection control, growth and development, and psychosocial factors.

1. Infection Control and Hygiene

• The urinary tract is sterile, meaning any bacteria introduced can lead to infection.

• Nurses must follow proper hygiene to prevent urinary tract infections (UTIs).

• Ways to prevent UTIs:

  • Encourage proper perineal hygiene (wiping front to back).

  • Ensure adequate fluid intake to flush out bacteria.

  • Educate patients to avoid holding in urine for too long.

  • For catheterized patients:

    • Maintain a closed drainage system.

    • Perform routine catheter care.

2. Growth and Development Considerations

• Toddlers & Children:

  • Potty training starts around 2-3 years old.

  • Nighttime control develops later than daytime control.

• Adults:

  • Usually have full control of urinary elimination.

• Older Adults:

  • Weakened bladder muscles can cause urinary incontinence.

  • Increased risk for UTIs and urinary retention.

  • Medications (e.g., diuretics) can affect urination patterns.

3. Psychosocial Implications

• Self-Image & Self-Esteem:

  • Patients with incontinence may feel embarrassed or anxious.

  • Urinary diversions (e.g., urostomy) may cause body image concerns.

• Nursing Role:

  • Provide emotional support and educate patients on managing their condition.

  • Encourage open conversations about urinary health without stigma.

Page 7: Physiology and Pathophysiology

Key Concepts

• Fluid Balance: Importance for homeostasis.

• Normal Urine Production: Anatomy and physiology behind urine formation and micturition.

• Urinary Alterations: Understanding various pathophysiological changes.

Communication Principles

• Addressing issues related to self-concept and sexuality in discussions with patients.

Slide 8: Nursing Process in Urinary Elimination

The nursing process is a structured, step-by-step approach to patient care. It consists of five phases:

1. Assessment – Collecting data about the patient’s urinary function.

2. Nursing Diagnosis – Identifying urinary issues based on assessment.

3. Planning – Setting patient-centered goals and priorities.

4. Implementation – Performing nursing interventions.

5. Evaluation – Determining if interventions were effective.

Page 11: Critical Thinking in Urinary Elimination

The nursing process is a structured approach to providing patient care. It includes assessment, diagnosis, planning, implementation, and evaluation.

1. Assessment (Slide 11-13 cover this in more detail)

• Through the patient’s eyes → Understand their concerns and experiences with urinary health.

• Evaluate self-care ability → Can the patient manage their urinary needs independently?

• Consider cultural factors → Some cultures have taboos or preferences about discussing urination.

• Assess environmental factors → Does the patient have access to a restroom or assistance if needed?

• Nursing history focus:

  • Patterns of urination → Frequency, urgency, hesitancy, retention.

  • Symptoms of urinary alterations (See Table 46.2).

Slide 12: Physical Assessment in Urinary Elimination

Slide 12: Physical Assessment in Urinary Elimination

A physical assessment helps identify urinary retention, infections, incontinence, and skin breakdown.

1. Kidneys – Physical Assessment

• Auscultation (Listening with a Stethoscope)

  • Why? To detect renal bruits (abnormal blood flow sounds which sounds like) that may indicate kidney disease.

• Palpation (Feeling the Kidneys with Hands)

  • Why? Checks for tenderness (sign of infection or kidney stones).

  • How? Palpate the costovertebral angle (CVA) on the back near the spine.

2. Bladder – Physical Assessment

• Inspection (Looking at the Lower Abdomen)

  • Why? A visibly distended (swollen) bladder may indicate urinary retention.

• Palpation (Feeling for Fullness or Pain)

  • Why? Checks if the bladder is overfilled (urine retention).

  • How? Lightly press above the pubic symphysis (lower abdomen).

• Bladder Scan (Using an Ultrasound to Check for Urine Retention)

  • Why? Non-invasive test to see how much urine is left in the bladder after voiding.

3. External Genitalia – Physical Assessment

• Inspection (Checking for Abnormalities in the Urethra/Genitals)

  • Why? Detects infection, irritation, swelling, lesions, or discharge.

  • What to Look For?

    • Redness/swelling → Possible infection or inflammation.

    • Lesions/sores → Could indicate STIs or skin breakdown.

    • Discharge → May indicate a UTI or other infection.

4. Perineal Skin – Physical Assessment

• Inspection (Checking Skin Around the Perineum and Buttocks)

  • Why? Prolonged urine exposure can cause skin breakdown.

  • What to Look For?

    • Redness or irritation → Possible urine-associated dermatitis.

    • Open sores or ulcers → May indicate severe skin breakdown in incontinent patients.

  • Nursing Actions:

    • Keep the perineal area clean and dry.

    • Use barrier creams for skin protection in incontinent patients.

Why is Physical Assessment Important?

✔ Helps detect urinary retention, infections, and incontinence early.
✔ Prevents skin breakdown and discomfort in patients with urinary problems.
✔ Guides nursing interventions and diagnostic tests.

This slide focuses on physically assessing the kidneys, bladder, genitals, and skin to identify urinary health issues.

Slide 13: Assessment of Urine

Assessing urine characteristics helps detect kidney function, hydration status, and possible infections.

1. Measuring Intake & Output (I&O)

• Intake: Includes all fluids consumed (oral, IV).

• Output: Includes all urine excreted.

• Normal urine output: 30 mL/hour or more

• Less than 30 mL/hour for 2+ hours → Possible kidney dysfunction

2. Urine Characteristics

• Color:

  • Pale yellow → Normal

  • Dark amber → Dehydration

  • Red or pink → Blood in urine (Hematuria)

• Clarity:

  • Clear → Normal

  • Cloudy → Possible infection

  • Foamy → Possible kidney disease (proteinuria)

• Odor:

  • Mild smell → Normal

  • Strong/foul odor → UTI or dehydration

  • Sweet/fruity smell → Diabetes (glucose in urine)

3. Laboratory & Diagnostic Testing

• Urinalysis: Checks for bacteria, protein, glucose, ketones, and blood in urine.

• Urine Culture: Identifies bacterial infections (UTIs).

• Specific Gravity: Measures urine concentration (hydration status).

  • Low (<1.005) → Overhydration

  • High (>1.030) → Dehydration

Why is Urine Assessment Important?

✔ Early detection of infections, dehydration, and kidney problems.
✔ Helps monitor patient hydration status.
✔ Guides treatment decisions for urinary disorders.

Slide 14: Nursing Diagnosis in Urinary Elimination

A nursing diagnosis identifies patient problems related to urinary health. This helps in planning appropriate interventions.

1. Common Nursing Diagnoses for Urinary Elimination

• Urinary Incontinence (Loss of bladder control)

  • Types:

    • Functional incontinence → Unable to reach the toilet in time.

    • Overflow incontinence → Bladder overfills and leaks.

    • Reflex incontinence → No sensation of needing to urinate (neurological issue).

    • Stress incontinence → Leaks with sneezing, laughing, or coughing.

    • Urge incontinence → Sudden, intense need to urinate.

• Urinary Tract Infection (UTI)

  • Bacterial infection in the urinary system.

  • Symptoms: Burning, frequent urination, cloudy/foul-smelling urine.

• Urinary Retention (Inability to empty the bladder fully)

  • Can lead to bladder distention, discomfort, and infection risk.

  • Causes: Nerve damage, prostate issues, anesthesia, or medication effects.

• Impaired Self-Toileting

  • The patient cannot get to the bathroom independently due to mobility issues, weakness, or cognitive impairment.

• Impaired Skin Integrity (Perineal Area)

  • Caused by prolonged exposure to urine in incontinent patients.

  • Can lead to irritation, rashes, or pressure ulcers.

2. Why Are Nursing Diagnoses Important?

✔ Help nurses develop individualized care plans.
✔ Allow early identification and treatment of urinary issues.
✔ Improve patient comfort, dignity, and independence.

This slide focuses on diagnosing urinary problems to plan effective nursing care.

Slide 15: Planning & Outcomes Identification in Urinary Elimination

The planning phase of the nursing process involves setting goals and expected outcomes to improve urinary health.

1. Establishing Patient Outcomes

• Goals should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).

• Examples of patient-centered goals:

  • Short-term goal: “The patient will urinate at least every 3-4 hours without discomfort.”

  • Long-term goal: “The patient will maintain normal bladder function and prevent infections.”

  • “The patient will remain continent by practicing pelvic floor exercises (Kegels) daily.”

2. Setting Priorities in Urinary Care

• High Priority:

  • Acute urinary retention → Immediate intervention needed.

  • Severe UTI with fever → Risk of kidney infection (pyelonephritis).

• Moderate Priority:

  • Stress or urge incontinence → Requires long-term management.

• Low Priority:

  • Mild nocturia (frequent urination at night) → Can be managed with fluid adjustments.

3. Teamwork & Collaboration in Urinary Health

• Work with other healthcare professionals to improve patient outcomes:

  • Urologists → For patients with chronic urinary conditions.

  • Physical therapists → For pelvic floor strengthening exercises.

  • Dietitians → To recommend hydration and dietary changes.

  • Occupational therapists → To help patients with self-toileting strategies.

Why is Planning Important?

✔ Helps organize patient care and prevent complications.
✔ Ensures nursing interventions are effective.
✔ Promotes patient independence and well-being..

Slide 16: Implementation – Health Promotion in Urinary Elimination

In the implementation phase, nurses carry out interventions to improve urinary function and prevent complications.

1. Patient Education

• Teach patients about healthy urinary habits and infection prevention.

• Encourage early reporting of urinary symptoms like pain, frequency, or leakage.

2. Promoting Normal Micturition (Urination)

• Maintaining Elimination Habits:

  • Encourage patients to urinate regularly instead of holding in urine.

  • Provide privacy and a comfortable environment for urination.

• Maintaining Adequate Fluid Intake:

  • Increase water intake (unless contraindicated) to prevent dehydration and UTIs.

  • Recommend 1.5 to 2 liters/day (unless the patient has a fluid restriction).

• Promoting Complete Bladder Emptying:

  • Encourage double voiding → Urinate, pause, then try again.

  • Timed voiding → Scheduling bathroom trips every few hours.

  • Kegel exercises → Strengthen pelvic muscles to prevent incontinence.

3. Preventing Urinary Tract Infections (UTIs) (See Box 46.10)

• Hygiene Tips:

  • Wipe front to back (especially for female patients).

  • Avoid perfumed soaps or sprays in the perineal area.

• Lifestyle Adjustments:

  • Urinate before and after sexual activity.

  • Avoid excessive caffeine, alcohol, and spicy foods (can irritate the bladder).

• Catheter Care:

  • Keep the catheter closed and below bladder level.

  • Perform routine perineal care to prevent infections.

Why is Health Promotion Important?

✔ Helps prevent urinary retention, infections, and incontinence.
✔ Encourages patients to take control of their urinary health.
✔ Reduces hospital stays and complications.

Slide 17: Implementation – Acute Care (Catheterization)

In acute care settings, urinary catheterization is sometimes necessary to manage urinary retention, surgery recovery, or critical illness.

1. Catheterization – When is it Needed?

• Urinary retention (inability to empty the bladder).

• Surgical procedures (especially abdominal or pelvic surgeries).

• Severe urinary incontinence that cannot be managed otherwise.

• Monitoring urine output in critically ill patients.

2. Types of Urinary Catheters

3. Catheter Sizes & Maintenance

• Size selection:

  • Adult women: 14-16 Fr (French gauge).

  • Adult men: 16-18 Fr.

• Routine Care:

  • Keep the catheter below the bladder level to prevent backflow.

  • Perform perineal hygiene daily to prevent infection.

  • Empty the drainage bag when it is ⅔ full.

4. Preventing Catheter-Associated Urinary Tract Infections (CAUTI) (Box 46.10)

• Use catheters only when absolutely necessary (remove as soon as possible).

• Maintain a closed drainage system (do not disconnect tubing unnecessarily).

• Keep the catheter and perineal area clean.

• Encourage proper hydration to flush bacteria from the urinary tract.

Why is Acute Care Implementation Important?

✔ Ensures proper urine drainage in patients with retention or surgical needs.
✔ Prevents CAUTI and other catheter-related complications.
✔ Improves patient comfort and recovery outcomes.

This slide focuses on nursing interventions for catheter use and infection prevention.

Slide 18: Implementation – Removal & Alternatives to Catheterization

Once a catheter is no longer necessary, nurses should remove it promptly to prevent complications like Catheter-Associated Urinary Tract Infections (CAUTI).

1. Removing an Indwelling (Foley) Catheter

• Check for a doctor’s order before removal.

• Deflate the balloon by withdrawing sterile water using a syringe.

• Gently remove the catheter while ensuring patient comfort.

• Encourage the patient to void within 6 hours after removal.

• Monitor for urinary retention or discomfort.

2. Alternatives to Urethral Catheterization

If a catheter is not necessary, consider these alternatives:

3. Urinary Diversions (For Patients with Bladder Removal or Dysfunction)

• Ileal Conduit → A section of the intestine is used to create a pathway for urine to exit through a stoma.

• Neobladder → A new bladder is surgically created from intestinal tissue.

• Urostomy → Urine is redirected to an opening in the abdominal wall.

4. Medications for Urinary Issues

• Anticholinergics → Reduce bladder spasms (e.g., oxybutynin).

• Alpha-blockers → Help relax bladder muscles (e.g., tamsulosin for enlarged prostate).

• Diuretics → Increase urine production (e.g., furosemide for fluid overload).

Why is This Important?

✔ Prevents infections and complications by avoiding unnecessary catheter use.
✔ Encourages bladder retraining for patients recovering from catheterization.
✔ Provides alternative options for patients with long-term urinary issues.

This slide focuses on safe catheter removal and alternatives to long-term catheter use.

Slide 22: Implementation – Continuing & Restorative Care in Urinary Elimination

This section focuses on long-term urinary management for patients with chronic conditions, incontinence, or bladder dysfunction.

1. Lifestyle Changes for Urinary Health

• Encourage fluid intake (unless contraindicated) to promote healthy urination.

• Reduce caffeine, alcohol, and acidic foods that can irritate the bladder.

• Maintain a healthy weight to reduce pressure on the bladder.

2. Pelvic Floor Muscle Training (Kegel Exercises)

• Strengthens muscles that control urination.

• Recommended for patients with stress or urge incontinence.

• How to Perform:

  • Contract pelvic muscles as if stopping urine flow.

  • Hold for 3-5 seconds, then relax.

  • Repeat 10-15 times, 3x a day.

3. Bladder Retraining for Incontinence

• Helps regain control over urination habits.

• Steps in Bladder Retraining:

  • Encourage scheduled voiding (every 2-3 hours).

  • Gradually increase the time between voids.

  • Use distraction techniques to manage urgency.

4. Toileting Schedules for Dependent Patients

• Helps patients with mobility limitations or cognitive impairment.

• Nurses assist with regular bathroom trips to prevent incontinence.

5. Intermittent Catheterization for Chronic Retention

• Used for patients who cannot empty their bladder fully.

• Less risk of infection compared to indwelling (Foley) catheters.

• Can be performed by nurses or trained patients at home.

6. Skin Care for Incontinent Patients

• Prolonged urine exposure can cause skin breakdown (incontinence-associated dermatitis).

• Nursing interventions:

  • Keep the skin clean and dry.

  • Apply barrier creams to protect against irritation.

  • Use absorbent pads or briefs as needed.

Why is Restorative Care Important?

✔ Helps patients regain independence and improve quality of life.
✔ Prevents complications like infections, skin breakdown, and social embarrassment.
✔ Supports long-term bladder health and comfort.

Slide 20: Evaluation in Urinary Elimination

Evaluation is the final step in the nursing process. It helps determine if nursing interventions have improved the patient’s urinary health.

1. Evaluating Through the Patient’s Eyes

• Ask the patient about their urinary health improvements:

  • "Do you feel more comfortable when urinating?"

  • "Are you experiencing less leakage or discomfort?"

• Assess their ability to manage self-care:

  • Can they follow fluid intake recommendations?

  • Can they perform Kegel exercises or bladder retraining?

2. Assessing Patient Outcomes

• Compare actual results with the expected goals:

  • Goal Met: Patient maintains normal voiding patterns without discomfort.

  • Goal Partially Met: Some improvement, but urinary issues persist.

  • Goal Not Met: No improvement, requiring reassessment and adjustment of care plan.

• Signs of Positive Progress:
  ✅ Patient voids without discomfort every 3-4 hours.
  ✅ Urine is clear, normal color, and odor.
  ✅ No signs of urinary retention or infections.

• When to Adjust the Care Plan:
  ❌ Patient still experiences frequent UTIs.
  ❌ Continues to have incontinence episodes despite interventions.
  ❌ Unable to empty bladder completely, leading to retention.

3. Next Steps if Goals Are Not Met

• Reassess the patient:

  • Are they following bladder training techniques correctly?

  • Are there new risk factors (medications, mobility changes, etc.)?

• Modify interventions:

  • Increase fluid intake or dietary changes.

  • Adjust toileting schedules or bladder retraining methods.

  • Consider medications or referral to a specialist.

Why is Evaluation Important?

✔ Ensures that nursing interventions are effective.
✔ Helps adjust treatment plans to meet patient needs.
✔ Improves patient outcomes and quality of life.

This slide focuses on measuring success in urinary care and adjusting plans when needed.

Slide 23: Safety Guidelines for Nursing Skills in Urinary Elimination

Ensuring patient safety is a top priority when performing urinary elimination procedures.

1. Follow Principles of Asepsis (Sterile & Medical Asepsis)

• When inserting a Foley catheter, use surgical (sterile) asepsis to prevent infection.

• For routine perineal care and catheter maintenance, use medical asepsis (clean technique).

2. Identify Patients at Risk for Latex Allergies

• Patients at higher risk:

  • Those with frequent medical procedures or catheter use.

  • Patients with spina bifida, multiple surgeries, or healthcare exposure.

• Use latex-free catheters and gloves for allergic patients.

3. Identify Patients with Allergies to Povidone-Iodine (Betadine)

• Povidone-iodine is commonly used for skin antisepsis before catheter insertion.

• If allergic, provide an alternative antiseptic like chlorhexidine.

4. Proper Positioning for Catheterization

• Female patients: Place in dorsal recumbent position (lying on back with knees bent).

• Male patients: Place supine with legs extended.

5. Preventing Falls & Injury in Patients with Urinary Issues

• Patients with urgency, nocturia, or incontinence are at higher risk for falls.

• Nursing actions:

  • Keep bedside commodes or urinals accessible.

  • Ensure proper lighting and clear walkways at night.

  • Assist with toileting schedules for high-risk patients.

Why Are Safety Guidelines Important?

✔ Reduces risk of infections (especially catheter-associated UTIs).
✔ Prevents allergic reactions from medical materials.
✔ Enhances patient comfort and safety during urinary procedures.

This slide focuses on essential safety measures when handling urinary care procedures.