Urinary Elimination

by:

MS. LOURADEL MATOL ULBATA, MAN, RN
LECTURER
Urinary Elimination
Urinary Elimination is a basic function of the kidneys,
whereby the waste products are excreted (urea,
ammonia, creatinine, and uric acid).
Urine consists of organic solutes such as urea,
ammonia, creatinine, and uric acid
Inorganic solutes include sodium, chloride, potassium
sulfate, magnesium, & phosphorus
Urination, micturation, and voiding are terms describe
the process of urine elimination from the urinary
bladder.
Anatomy & Physiology

Kidneys
Ureters
Bladder
Urethra
Nephron
Functional unit of kidney
1 million per kidney
1200 ml blood pass through the
kidney/min
Wastes cannot be excreted as solids;
must be excreted in solution
Normal urine production = 1 ml / minute
Kidneys must produce 30 ml/hr minimum

Kidneys and Ureters
Maintain composition and volume of body fluids
Filter and excrete blood constituents not needed, retain
those that are needed
Urine from the nephrons empties into the renal
pelvisuretersbladder.
Bladder
Bladder is a hollow, muscular organ that serves as a
reservoir for urine and as the organ of excretion.
Composed of three layers of muscle tissue called detrusor
muscle.
Detrusor muscle allows the bladder to expand as it fills
with urine, and to contract to release urine.
Sphincter guards the opening between urinary bladder and
urethra.
Normal bladder capacity is between 300-600 ml of urine.
Urethra
The urethra extends from the bladder to the
urinary meatus (opening).
Serves as a passageway of urine from the
bladder to the exterior of the body.
Male urethra is about 20 cm long and serves as a
passageway of semen as well as urine.
Female urethra is about 3-4 cm, thats why
women are particularly prone to urinary tract
infections.
Definitions
Urine fluid within the bladder


Urinary elimination the process of
releasing excess fluid and metabolic wastes
Elimination
The average person eliminates 1500-
3000mls of urine each day


Urination occurs several times a day

When the bladder is filled with
approximately 150-300ml urine, we feel the
need to have to urinate

This distention causes increased fluid
pressure, stimulating stretch receptors in the
bladder wall creating a desire to empty itself

Patterns of urinary elimination
depend on
Physiologic

Emotional

Social factors
Examples of these factors
The degree of neuromuscular development are
you a paraplegic, do you have a spinal cord injury
or spinal bifida

A persons circadian rhythm

Opportunities for urination

anxiety

Process of Micturation
Process of emptying the bladder

Urine collects in the bladder until the pressure stimulates the
nerve endings in the bladder wall called (strech receptors).

Those receptors transmit impulses to the spinal cord causing the
internal sphincter of the bladder to relax and stimulate the urge to
urinate.

Act of Micturition
Urine moves from the kidneys through ureters via
peristaltic waves into bladder.
Bladder fills & detrusor muscles sense pressure
Structures and functions for voluntary control of
voiding:
-External sphincter- restrain or interrupt act
-Conscious brain- starts act
-Intact spinal cord- needed or else message from the
brain is not received.
Physical Characteristics of Urine
This includes its:

volume
Color
Clarity
Odor

Characteristics of Urine
Amount
1200 ml/day
average

pH 4.6 8.0


Turbidity

Specific gravity
1.010 1.030

Constituents


VOLUME
Remember that we like to see at least 30cc/hr in
adults

Common causes:

low fluid intake
excess fluid loss
kidney dysfunction
diuretic medication
endocrine diseases
COLOR
**Light yellow is normal

Abnormal colored urine:
Dark amber dehydration or liver or gallbladder
Brown dehydration or liver or gallbladder
Reddish-brown hematuria or menses
Cloudy could be an infection
Orange, green, blue from water soluble dyes
CLARITY
(This means, how clear is the urine)

**Urine should be clear**

ABNORMAL URINE :
Cloudy, can be from infection or stasis
Urine Specimen Collection
Why do we do this?


We are trying to identify any
microorganisms under a microscope
Common Urine Specimens
Collected By Nurses
Voided specimens

Clean-catch specimens midstream urine

Catheter specimens

24 hour specimens
VOIDED SPECIMENS
** Is a sample of fresh urine collected in a clean
container
** The 1
st
void of the day is preferred (other times
of the day will work) because it is likely to contain
a concentrated amount of urinary components that
have accumulated overnight
** This specimen should be refrigerated if it will
not be looked at in the lab right when its sent
CLEAN-CATCH SPECIMENS
Also known as midstream. This is a
sterile collection which means:

The container that the urine sample goes in
is handled in a way as to not get microbes
on or in the container----

Clean-Catch
Patient uses 2-3 betadine swabs to clean
meatus (both men and women can do this)
Patient starts to void into toilet, then
collects the urine after the initial stream has
been released. We dont want the betadine
or any germs that we normally have on us to
be collected, we are looking for microbes
Clean-catch
These are most preferred by Drs.

If the lab cannot run this specimen in under
an hour, the specimen is labeled and placed
in the refrigerator
CATHETER SPECIMENS
YOU MUST NEVER TAKE URINE FROM THE
HOLDING BAG. This urine has been sitting and
is full of its own germs

A nurse can clamp the tubing to a foley, clean the
self-sealing rubber lumen on the catheter, insert a
needle into this lumen and pull out urine and place
it in a sterile container.
Definitions
Hematuria urine containing blood
Pyuria urine containing pus
Proteinuria urine containing plasma
proteins
Glycosuria urine containing glucose
Ketonuria urine containing ketones
Abnormal urinary elimination
patterns
Anuria absence of urine or <100ml/24hrs
It means that the kidneys are not forming
sufficient urine
Also called urinary suppression
The bladder is empty and the patient feels
no need to urinate
This is often confused with urinary
retention
Urinary retention

The bladder is full and the abdomen is full
of urine, it just isnt released from the
sphincter
The patient has discomfort and at times,
begs you to help him to urinate
Credes Method
The application of downward pressure on
the abdominal wall with pressure over the
symphysis pubis to aid in expelling urine

Used while catheter is in place or while
urinating in toilet, pt or nurse can perform
this technique
Oliguria
Urine output is < 400ml/24 hours
Oliguria indicates inadequate elimination of
urine
May be a sign that the bladder is not
emptying completely when you are trying to
void = residual urine
Residual Urine
When more than 50ml of urine remains in
the bladder after voiding. This sitting or
stasis of urine causes bladder infections

Patient tries to void, states that he is done
and then is cathd to check residual
Polyuria
Is a greater than normal urinary volume

As in diabetics, they void and void and
void, in DI, they void, void, void

Drinking caffeine or lots of fluids or taking
meds such hydrochlorothiazide can increase
urination
Nocturia
Is nightime urination

You are supposed to sleep at night, not void
a lot
In men, can be r/t enlarged prostate which
encircles the urethra, interfering with total
emptying = more frequent small voids
Dysuria
Difficult or uncomfortable voiding

Can be d/t trauma to urethra or bladder
infections
Frequency (need to void often) and urgency
(strong feeling that urine must be eliminated
quickly) accompany dysuria
Incontinence
Means:
Inability to hold or control urine or bowel
elimination

Once a person has been toilet trained, this is an
abnormal finding
Interventions for Urinary
Incontinence
Bladder training/ Habit training

External urinary device
- Condom Catheter

Indwelling catheter-LAST resort
Factors Affecting voiding
1. Developmental considerations
2. Food and fluid intake
3. Psychological factors
4. Muscle tone/ Activity
5. Pathologic conditions
6. Lifestyle
7. Medications
Developmental Considerations
Children
Toilet training can start at the age of 2
years.
Nocturnal enuresis or bed wetting, is the
involuntary passing of urine during sleep.
Geriatric Considerations
Decreased ability of kidneys to concentrate urine and
decreased bladder capacity
= nocturia
Decreased muscle tone of bladder
= increased frequency
Decreased bladder contractility & stasis
= increased frequency of UTI
Changes in cognition and mobility (in some)
= increased incontinence issues

Diseases Associated With Renal
Problems
Congenital urinary tract abnormalities
Polycystic kidney disease
Urinary tract infection
Urinary calculi
Hypertension
Diabetes mellitus
Prostate hypertrophy
Nursing Assessment of
Urinary Function
Nursing history
Physical assessment of urinary system
Hydration status
Examination of urine
Data from diagnostic tests and procedures
NURSING HISTORY
Usual patterns
Recent changes
Difficulties
Artificial Orifices
Physical Assessment
Kidneys:
R kidney located
12 rib
L kidney lower
Tenderness during
palpation at
costoverterbral
angle?
Bladder:
Below symphysis
pubis
Supine position to
examine
Observe-roundness
Palpate-tenderness,
how high it distends
Percussion- full
bladder dull sound

Assessment: Lab Results
Urinalysis- WBC, RBC, protein,
glucose, bacteria
= abnormal constituents
BUN (blood urea nitrogen) end product of protein
metabolism 10-20 mg/dL
Increased BUN (azotemia) signifies impaired kidney function
affected by diet (hi protein intake) and fluids (dehydration)

Decreased BUN signifies impaired liver function

Many drugs elevate BUN (antibiotics, lasix +++)


Assessment: Lab Results
Serum creatinine - by product of muscle
metabolismexcreted entirely by
kidneys Normal = 0.5-1.2 mg/dL
Increased levels signify renal impairment
BUN: Creatinine ratio- 20:1 when
both rise together indicates kidney failure
or disease
Assessing Urinary Retention
Feeling of fullness
Voiding small amounts
< 50 ml
Normal intake/inadequate
output
Distended bladder
Discomfort
Bladder Scan
If > 300 ml should catheterize
Patients at Risk for UTIs
Women due to short urethra.
Postmenopausal women
Individuals with indwelling urinary catheter
Individual with diabetes mellitus
Elderly people
Nursing Dx R/T Urinary
Elimination
Impaired urinary elimination
Urinary retention
Functional urinary
incontinence
Overflow urinary incontinence
Stress urinary incontinence
Reflex urinary incontinence
Urge urinary incontinence
Total urinary incontinence
Risk for infection r/t urinary
retention and/or urinary
catheterization
Risk for impaired skin integrity r/t
urinary incontinence
Situational low self esteem r/t
incontinence
Outcome Criteria
Patient will:
Empty bladder completely at regular
intervals
Decrease episodes of incontinence
Maintain regular urinary elimination
pattern
Develop adequate Intake/Output
Have decreased dysuria
General Measures To Promote
Urination
Providing privacy

Assuming a natural position for urination (men
standing, women sitting up)

Adequate fluid intake

Using stimuli such as running tap water to initiate
urination
Assistance with urinary
elimination
Stable clients can get to the toilet with little
to no assistance

Others who are unstable, need more
assistance

Commode, urinal or bedpan is used
Commode
Is a chair with an opening in the seat under
which a receptacle is placed

This is placed near the bedside and is
cleaned IMMEDIATELY after use

DONOT leave your B.S. commode full,
rinse it out with water
Urinal
A cylindrical container or toilet seat-like for
collecting urine

Men have it made once again, its easier for men
to use a urinal than it is for women

Male urinals are slanted so urine will not spill out.
ALWAYS OFFER MEN A URINAL THAT HAS
BEEN EMPTIED
Urinal
If pt needs help:
Pull curtain for privacy
Don gloves
Ask pt to spread his legs
Place a chux pad between the legs
Hold the urinal by its handle
Place urinal between the pts legs and set it on the
bed
Lift the penis and place it well within the urinal

Urinal
Carefully remove the urinal and chux pad
Wash your hands and offer the pt no rinse
soap
Record your findings
Using a bedpan
A fracture pan is a modified version of a
conventional bedpan

Pt can lift self up or can be rolled to place pan
ALWAYS USE CHUX PADS for leakage
Wipe pt thoroughly and offer no rinse soap for
them to use
ALWAYS EMPTY BEDPAN IMMEDIATELY
Catheterization
Act of applying or inserting a hollow tube
Used for:
Keeping incontinent pts dry because you control it, done
every 6 hours
Relieving bladder distention when pts cannot void on own
To assess fluid balance accurately such as after kidney
transplant surgery
To keep the bladder from becoming distended during
surgery or procedures
To measure residual urine
To obtain sterile urine specimens
To instill medication within the bladder
Catheters
Many catheters are made of latex
however

If your patient has a latex allergy, pt needs
latex-free catheters
3 Types of catheters
External


Straight


Retention
External catheters
Urine collecting device
applied to skin such as a
condom catheter and a U-bag or urinary bag

External catheters are more effective for male
clients
Condom cath goes on like a condom, rolls on and
is attached to a drainage bag
3 problems with condom
catheters
1. Condom sheath can be too tight causing
decrease circulation of blood flow to skin
and tissues of the penis

2. Moisture accumulates under the sheath
and causes skin breakdown

3. Condom catheters frequently leak
U-Bag
Usually used to collect
urine specimens from
infants, its attached with adhesive backing
and surrounds the genitals

Once the urine is in the bag, the bag is
removed and urine is taken from the corner
of the bag
Straight catheter for urinary
retention
Is a urine drainage tube inserted to collect urine
thats retained (held) in the bladder and then its
removed. Or, provides a sterile specimen
Its usually a one time deal cath
Used when pts are having trouble urinating or
having urinary retention
You must remove the urine and hope they will
urinate next time or you may be straight cathing
them again
Foley Catheter(sometimes referred
to as a retention catheter
Also called an indwelling catheter and is left in
place for a period of time (retaining the catheter,
hence the name retention catheter)
The most common type is a foley catheter
These catheters are secured with a balloon that is
inflated
It is connected to large holding bag that contains
clamps for securing the bag to the bed or IV pole
Inserting a catheter
Done under STERILE TECHNIQUE
Can be done by the pt or parent of the pt
Connecting a closed drainage
system
Once your indwelling or Foley catheter is placed,
you must connect a drainage bag

There is usually a calibrated bag that opens at the
bottom with a clamp

The tubing to the drainage bag is long and
becomes compressed and gravity flow becomes
impaired. The cath. must be manipulated
frequently
Closed-system drainage bag
This drainage bag is always secured below
the pts bladder to ensure proper drainage

The Foley catheter itself should be changed
every 2 weeks
This drainage bag system should be
completely changed every 4weeks if long
term use of a Foley is ordered by the Dr.
Providing catheter care
A retention or Foley catheter keeps the
meatus slightly dilated and therefore
provides a means for a direct pathway to the
bladder where an infection can develop

It is believed that bacteria that form on
catheter tubing form a biologic structure
which protects them from antibiotics
Catheter care
Catheter can be cleaned with betadine
swabs by starting near the meatus and
stroking downward towards the pts feet.
The use of 3-4 swab sticks is acceptable.
Soap and water may be used in the same
direction as mentioned above
Cath care should be performed with bathing
everyday
Catheter Irrigation
Flushing the lumen of a catheter

This helps to keep the tubing free of debris

Usually, good oral intake is all that it takes
to keep tube free and clear d/t enough
flowing urine passing through
Catheter Irrigation
The most common way to irrigate a catheter
is to remove the catheter tubing from the
drainage bag and place a syringe filled with
NS into the tube and gently flush. All of the
NS will travel back into the Pt so youll
need to reconnect the Foley tubing to the
drainage bag. Although this is the most
common way to irrigate a Foley, it has the
potential to cause infection
Using a closed system to irrigate
a catheter
This requires NOT separating the tubing at all
This type of irrigation requires that your Foley
contains a self-sealing port on it where you can
insert an 18 or 19 gauge needle into the port and
gently pushes in the NS

The urine can then freely flow back into the
reservoir, holding portion of the bag
Continuous Irrigation
This method instills irrigating solution into
the catheter by gravity over a period of days
This type of irrigation is used in prostate or
other urologic surgery where blood clots
and tissue debris can clog up the tubing not
allowing urine to freely flow
Removal of Indwelling Catheter
The best time to remove a catheter is in the
morning after a pt has had a good night
sleep and
You can address urinary issues while pt is
awake, sometimes, when catheter is
removed, pt has some retention. On
occasion, a pt will have to be st. cathd
temporarily
Urinary Diversions
One or both ureters are implanted or placed
somewhere else
Ureter can brought to and through the skin and
attached to the bowel called an ileal conduit
Urinary diversion that discharges urine from an
opening in the skin, this is called a urostomy and
the pt may catheterize through their own belly-
button to get the urine out
Medications Affecting Urinary
Elimination
Antibiotics work against infection
Bactrim, Levaquin, Cipro
Urinary antispasmotics relieve spasms with
UTI
Ditropan, Pro-Banthine
Diuretics.increase urinary output
Lasix, Diuril
Cholinergicsincrease muscle tone & function
Used for urinary retention, neurogenic bladder
Urecholine


Urinary Specimen Collection

Routine urinalysis
Clean-catch/midstream urine
Sterile specimen ( catheterization
or from indwelling catheter)
24 hr. urine

Evaluating Urinary
Elimination
Frequency
Amount
Ease/Difficulty
Color
Appearance
Odor