chapter 45: urinary elimination

Chapter 45: Urinary Chapter 45: Urinary EliminationElimination

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

AnatomyAnatomy• KidneysKidneys remove wastes from the blood to remove wastes from the blood to

form urine; play a key role in fluid and form urine; play a key role in fluid and electrolyte balanceelectrolyte balance

• UretersUreters transport urine from the kidneys transport urine from the kidneys to the bladderto the bladder

• The The bladder bladder holds urine until the urge to holds urine until the urge to urinate developsurinate develops

• Urine leaves the body through the Urine leaves the body through the urethraurethra• NephronNephron is working unit of kidney; forms is working unit of kidney; forms

urine; contains glomerulus surrounded by urine; contains glomerulus surrounded by Bowman’s capsuleBowman’s capsule– Bowman’s capsule, proximal convoluted tubule, Bowman’s capsule, proximal convoluted tubule,

loop of Henle, distal tubule, collecting ductloop of Henle, distal tubule, collecting duct

KidneyKidney

FiltrationFiltration

• Filtration of H2O, glucose, amino acids, Filtration of H2O, glucose, amino acids, urea, creatinine, and major electrolytes urea, creatinine, and major electrolytes into Bowman’s capsuleinto Bowman’s capsule

• Large proteins and blood cells do not Large proteins and blood cells do not normally filter through the glomerulusnormally filter through the glomerulus

• Proteinuria = the presences of large Proteinuria = the presences of large proteins in the urine; a sign of glomerular proteins in the urine; a sign of glomerular injuryinjury

• Glomerulus filters approximately 125 mL Glomerulus filters approximately 125 mL of filtrate per minuteof filtrate per minute

The KidneysThe Kidneys• Normal adult urine output is 1500 to 1600 Normal adult urine output is 1500 to 1600

mL/daymL/day• An output of < 30 mL/hr indicates possible An output of < 30 mL/hr indicates possible

renal alterationrenal alteration• Kidneys produce several substances vital to Kidneys produce several substances vital to

production of RBC, BP, and bone production of RBC, BP, and bone mineralizationmineralization

• Produces erythropoietin which stimulates RBC Produces erythropoietin which stimulates RBC production and maturation and prolongs the production and maturation and prolongs the life of the mature RBCslife of the mature RBCs– Patients with chronic alterations in kidney function Patients with chronic alterations in kidney function

cannot produce sufficient quantities of this cannot produce sufficient quantities of this hormone therefore they are prone to anemiahormone therefore they are prone to anemia

The Kidneys Cont’d.The Kidneys Cont’d.

• Renal hormones affect BP regulation in Renal hormones affect BP regulation in several waysseveral ways– Renin and angiotensin I and II cause Renin and angiotensin I and II cause

vasoconstrictionvasoconstriction– Aldosterone released resulting in water retentionAldosterone released resulting in water retention– Prostaglandin – maintains renal blood flow via Prostaglandin – maintains renal blood flow via

vasodilation vasodilation • Affect calcium and phosphate regulation by Affect calcium and phosphate regulation by

producing a substance that converts vit D producing a substance that converts vit D into its active forminto its active form– Renal bone disease results from demineralization Renal bone disease results from demineralization

of the bone cause by impaired calcium absorptionof the bone cause by impaired calcium absorption

Act of Urination Act of Urination “Micturition”“Micturition”

• Brain structures that influence Brain structures that influence bladder emptyingbladder emptying– Cerebral cortex, Thalamus, Cerebral cortex, Thalamus,

Hypothalamus, Brain StemHypothalamus, Brain Stem

• Normal voiding involves contraction Normal voiding involves contraction of the bladder muscles and of the bladder muscles and coordinated relaxation of the urethral coordinated relaxation of the urethral sphincter and pelvic floor musclessphincter and pelvic floor muscles

Act of Urination Cont’d.Act of Urination Cont’d.

• Factors influencing urinationFactors influencing urination– Amount of urine in the bladderAmount of urine in the bladder

•Adult normally holds 600mLAdult normally holds 600mL

•Child 150 – 200mLChild 150 – 200mL

– Increasing urine volume stimulates the Increasing urine volume stimulates the micturition center in the sacral spinal micturition center in the sacral spinal cordcord

– Normally voiding is a voluntary processNormally voiding is a voluntary process

Factors Influencing UrinationFactors Influencing Urination

•Disease ConditionsDisease Conditions– Prerenal: decreased blood flow to Prerenal: decreased blood flow to

and through the kidneysand through the kidneys– Renal: disease conditions of the Renal: disease conditions of the

renal tissuerenal tissue– Postrenal: obstruction in the lower Postrenal: obstruction in the lower

urinary tract that prevents urine urinary tract that prevents urine flow from the kidneysflow from the kidneys

Diseases That Influence Diseases That Influence UrinationUrination

• DiabetesDiabetes

• Multiple SclerosisMultiple Sclerosis

• BPH – Benign Prostatic HyperplasiaBPH – Benign Prostatic Hyperplasia

• Cognitive DisordersCognitive Disorders– Alzheimer’s DiseaseAlzheimer’s Disease

• End-Stage Renal DiseaseEnd-Stage Renal Disease– Requires dialysisRequires dialysis

Other Factors That Influence Other Factors That Influence UrinationUrination

• Socio-cultural FactorsSocio-cultural Factors– PrivacyPrivacy

• Psychological FactorsPsychological Factors– AnxietyAnxiety

• Fluid balanceFluid balance

• Surgical proceduresSurgical procedures

• MedicationsMedications

• Diagnostic examinationDiagnostic examination

Terminology to KnowTerminology to Know• NOCTURIANOCTURIA

• POLYURIAPOLYURIA

• OLIGURIAOLIGURIA

• DYSURIADYSURIA

• ANURIAANURIA

• DIURESISDIURESIS

• CYSTITISCYSTITIS

• HEMATURIAHEMATURIA

• PYLONEPHRITISPYLONEPHRITIS

• INCONTINENCEINCONTINENCE

• NOCTURNAL NOCTURNAL ENURESISENURESIS

Alterations in Urinary Alterations in Urinary EliminationElimination

• Urinary RetentionUrinary Retention– Accumulation of urine resulting from an inability Accumulation of urine resulting from an inability

of the bladder to empty properlyof the bladder to empty properly

•Bladder unable to respond to the micturition Bladder unable to respond to the micturition reflexreflex

• Possible CausesPossible Causes– Urethral obstructionUrethral obstruction

•Surgical traumaSurgical trauma

•Child birthChild birth

•Alterations in sensory innervationAlterations in sensory innervation

•AnxietyAnxiety

•Side effects of medicationsSide effects of medications

Alterations in Urinary Alterations in Urinary EliminationElimination

• Urinary tract infections (UTIs)Urinary tract infections (UTIs)– Most common healthcare associated Most common healthcare associated

infectioninfection•CatheterizationCatheterization

•Surgical ManipulationSurgical Manipulation

•75% – 95% Caused by E-Coli75% – 95% Caused by E-Coli

• Any condition resulting in urinary Any condition resulting in urinary retention (Kinked, obstructed or retention (Kinked, obstructed or clamped catheter) increases the risk of clamped catheter) increases the risk of bladder infectionbladder infection

Alterations in Urinary Alterations in Urinary EliminationElimination

• Urinary IncontinenceUrinary Incontinence– Involuntary urinationInvoluntary urination

• CausesCauses– AgingAging

•50% of all LTC residents suffer from 50% of all LTC residents suffer from incontinenceincontinence

• ComplicationsComplications– Skin breakdownSkin breakdown

Alterations in Urinary Alterations in Urinary EliminationElimination

• Urinary DiversionUrinary Diversion– Divert ureters to abdominal wall stomaDivert ureters to abdominal wall stoma– CausesCauses

•Cancer of the bladderCancer of the bladder

•TraumaTrauma

•RadiationRadiation

•Chronic cystitisChronic cystitis

– Nephrostomy – drainage via tube placed Nephrostomy – drainage via tube placed directly into the renal pelvisdirectly into the renal pelvis

Ileal ConduitIleal Conduit

NephrostomyNephrostomy

Normal vs Abnormal UrineNormal vs Abnormal Urine• NORMAL URINE VALUESNORMAL URINE VALUES

– APPEARANCE: ClearAPPEARANCE: Clear– COLOR: Amber yellowCOLOR: Amber yellow– ODOR: Slight ammoniaODOR: Slight ammonia– pH: 4.6 – 8.0pH: 4.6 – 8.0– PROTEIN: 0 – 8mg/dlPROTEIN: 0 – 8mg/dl– SPECIFIC GRAVITY: 1.005 – 1.030SPECIFIC GRAVITY: 1.005 – 1.030– LEUKOCYTES: NegLEUKOCYTES: Neg– NITRITES: NegNITRITES: Neg– KETONES: NegKETONES: Neg– CRYSTALS: NegCRYSTALS: Neg– GLUCOSE: Neg GLUCOSE: Neg – RBC: NegRBC: Neg– WBC: NegWBC: Neg

Normal vs Abnormal UrineNormal vs Abnormal Urine

• Abnormal FindingsAbnormal Findings– Increased pHIncreased pH

•Respiratory or metabolic alkalosisRespiratory or metabolic alkalosis

•Gastric suctioningGastric suctioning

•VomitingVomiting

•UTIUTI

– Decreased pHDecreased pH•Metabolic acidosisMetabolic acidosis

•DiabetesDiabetes

•DiarrheaDiarrhea

•Respiratory acidosisRespiratory acidosis

Normal vs Abnormal UrineNormal vs Abnormal Urine

– Increased proteinIncreased protein•DMDM

•CHFCHF

•Pre-eclampsiaPre-eclampsia

•GlomerulonephritisGlomerulonephritis

•Polycystic diseasePolycystic disease

– Decreased proteinDecreased protein•LupusLupus

•Heavy-metal poisoningHeavy-metal poisoning

•Bladder tumorBladder tumor

Normal vs Abnormal UrineNormal vs Abnormal Urine– Increased Specific GravityIncreased Specific Gravity

•DehydrationDehydration

•Glycosuria, proteinuriaGlycosuria, proteinuria

•FeverFever

•VomitingVomiting

•DiarrheaDiarrhea

– Decreased Specific GravityDecreased Specific Gravity•Over-hydrationOver-hydration

•Renal failureRenal failure

•HypothermiaHypothermia

•PyelonephritisPyelonephritis

Normal vs Abnormal UrineNormal vs Abnormal Urine

– Increased RBCsIncreased RBCs•GlomerulonephritisGlomerulonephritis

•Acute tubular necrosisAcute tubular necrosis

•CystitisCystitis

•Traumatic catheterizationTraumatic catheterization

– Increased WBCsIncreased WBCs•Bacterial infection in the urinary tractBacterial infection in the urinary tract

•GlomerulonephritisGlomerulonephritis

•Acute pyelonephritisAcute pyelonephritis

•LupusLupus

Infection Control and HygieneInfection Control and Hygiene

• The urinary tract is a sterile The urinary tract is a sterile environmentenvironment– Apply knowledge of medical and surgical Apply knowledge of medical and surgical

asepsis when providing care involving asepsis when providing care involving the urinary tractthe urinary tract

– Catheterization is a sterile techniqueCatheterization is a sterile technique– Perineal care and catheter care is a Perineal care and catheter care is a

clean procedureclean procedure

Psychosocial ConsiderationsPsychosocial Considerations

• Gender differencesGender differences– Males stand to urinateMales stand to urinate– Females sit to urinateFemales sit to urinate

• How many people lie down to How many people lie down to urinate??urinate??

Nursing Process and Alterations in Nursing Process and Alterations in Urinary FunctionUrinary Function

• AssessmentAssessment– Subjective InformationSubjective Information

•DIFFICULTY URINATING?DIFFICULTY URINATING?

•PAINFUL URINATION?PAINFUL URINATION?

• INCONTINENCE?INCONTINENCE?

•FREQUENCY?FREQUENCY?

•URGENCY?URGENCY?

•LEAKING?LEAKING?

Nursing Process and Alterations in Nursing Process and Alterations in Urinary FunctionUrinary Function

• AssessmentAssessment– Objective dataObjective data

•Assess Urine: color, odor, amountAssess Urine: color, odor, amount

•Review lab dataReview lab data

•See Box 45-3 (page 1137) for assessment See Box 45-3 (page 1137) for assessment questionsquestions

– Physical assessment Physical assessment •Abdominal distentionAbdominal distention

Common Urinary AlterationsCommon Urinary Alterations

• URGENCYURGENCY

• FREQUENCYFREQUENCY

• HESITANCYHESITANCY

• RETENTIONRETENTION

• DRIBBLINGDRIBBLING

• INCONTINENCEINCONTINENCE

• RESIDUAL URINERESIDUAL URINE

Diagnostic Examinations of the Diagnostic Examinations of the Urinary SystemUrinary System

• OBTAINING A URINE SPECIMENOBTAINING A URINE SPECIMEN– RANDOMRANDOM– CLEAN CATCH (MIDSTREAM)CLEAN CATCH (MIDSTREAM)– STERILESTERILE– TIMED COLLECTIONTIMED COLLECTION

Diagnostic Examinations of the Diagnostic Examinations of the Urinary SystemUrinary System

• TESTING THE URINETESTING THE URINE– CHEMICAL REAGENT STRIP (DIP STICK)CHEMICAL REAGENT STRIP (DIP STICK)

•BEDSIDE URINALYSISBEDSIDE URINALYSIS– pHpH– GLUCOSEGLUCOSE– BLOODBLOOD– KETONESKETONES– PROTEINPROTEIN

Diagnostic Examinations of the Diagnostic Examinations of the Urinary SystemUrinary System

• Testing the urineTesting the urine– Sterile specimenSterile specimen

•Straight cathStraight cath

•Aspiration from indwelling catheterAspiration from indwelling catheter

•Same procedure from urinary diversionSame procedure from urinary diversion

– Timed specimen to be sent to labTimed specimen to be sent to lab•EXAMPLE: 24-HrUrine for UUN (Urine Urea EXAMPLE: 24-HrUrine for UUN (Urine Urea

Nitrogen)Nitrogen)– Special container/PreservativeSpecial container/Preservative– MUST SAVE ALL URINE OR START OVERMUST SAVE ALL URINE OR START OVER– IceIce

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

• Clean catch or midstreamClean catch or midstream– Assemble equipment and instruct pt. on Assemble equipment and instruct pt. on

technique to obtain specimentechnique to obtain specimen

• Straight Cath (in and out cath)Straight Cath (in and out cath)– Assemble equipmentAssemble equipment– Explain procedure to pt.Explain procedure to pt.– Insert catheter using sterile techniqueInsert catheter using sterile technique– Send specimen to lab in sterile containerSend specimen to lab in sterile container

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

• Obtaining sterile specimen from Obtaining sterile specimen from existing urinary catheterexisting urinary catheter– Catheter must be clamped for about 30 Catheter must be clamped for about 30

mins prior to aspirationmins prior to aspiration– Using a syringe and large bore needle, Using a syringe and large bore needle,

access the collection port on the access the collection port on the catheter tubing and withdraw 5-10 mL catheter tubing and withdraw 5-10 mL of urine to send to labof urine to send to lab

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

• Non-Invasive examination of the Non-Invasive examination of the bladder and kidneysbladder and kidneys– X-RAY: KUB = kidneys, ureters, bladderX-RAY: KUB = kidneys, ureters, bladder

•Simple film, no prep neededSimple film, no prep needed•Determines size, shape, location and symmetryDetermines size, shape, location and symmetry

– CT ScanCT Scan•Detailed images of structures. Tumors and Detailed images of structures. Tumors and

obstructions may be visibleobstructions may be visible•Prep: NPO, variesPrep: NPO, varies•Determine patient allergy to iodine (injected Determine patient allergy to iodine (injected

during procedure)during procedure)

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

– IVP: Intravenous PyelogramIVP: Intravenous Pyelogram•Views collecting ducts, renal pelvis, ureters, Views collecting ducts, renal pelvis, ureters,

bladder and urethrabladder and urethra

•Prep: Bowel cleansingPrep: Bowel cleansing– Assess pt’s allergy to iodine and/or shellfishAssess pt’s allergy to iodine and/or shellfish

•Post-test encourage fluids to flush dye from Post-test encourage fluids to flush dye from systemsystem

– Monitor for delayed allergic reactionMonitor for delayed allergic reaction

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

– Ultrasound of the bladderUltrasound of the bladder

•Identifies gross renal structures and Identifies gross renal structures and structural abnormalitiesstructural abnormalities

•No prep requiredNo prep required

•Simple US (bladder scan) can be done Simple US (bladder scan) can be done on the nursing unit to evaluate on the nursing unit to evaluate retained urine (post-void residual – retained urine (post-void residual – PVR)PVR)

Nursing ImplicationsNursing ImplicationsDiagnostic Examinations of the Urinary Diagnostic Examinations of the Urinary

SystemSystem

• Invasive Examination of the kidneys Invasive Examination of the kidneys and bladderand bladder– CystoscopyCystoscopy

•Direct visualization of the bladder and urethraDirect visualization of the bladder and urethra– Specimen collectionSpecimen collection– Done using conscious sedationDone using conscious sedation

•Post-ProcedurePost-Procedure– Vital signsVital signs– I&OI&O– Describe urineDescribe urine– Encourage fluidsEncourage fluids

Nursing Interventions that Promote Nursing Interventions that Promote Normal UrinationNormal Urination

• Intake and OutputIntake and Output– INTAKE: monitoring and measuring all liquid taken inINTAKE: monitoring and measuring all liquid taken in

•Oral fluidsOral fluids

• IV fluidsIV fluids– OUTPUT: measure all fluids eliminated from the bodyOUTPUT: measure all fluids eliminated from the body

•UrineUrine

•Wound drainageWound drainage

•NG drainageNG drainage

•DiarrheaDiarrhea

Catheter Insertion Catheter Insertion Male and FemaleMale and Female

• Requires a provider orderRequires a provider order• Explain procedure to patientExplain procedure to patient• Assemble equipmentAssemble equipment• Assess patientAssess patient

– Do you need help?Do you need help?– Is the female patient able to maintain Is the female patient able to maintain

lithotomy position?lithotomy position?– Is your female patient obese?Is your female patient obese?

Suprapubic CathetersSuprapubic Catheters

• Surgical placement of a catheter Surgical placement of a catheter through the abdominal wall above through the abdominal wall above the symphysis pubis into the bladderthe symphysis pubis into the bladder– Appropriate for use in paraplegic, Appropriate for use in paraplegic,

quadraplegic and comatose patientsquadraplegic and comatose patients– Slightly less chance for infection over Slightly less chance for infection over

the long termthe long term

Condom CathetersCondom Catheters• For male patients onlyFor male patients only

• Alternative to catheterizationAlternative to catheterization

• Latex or silicone sheath that fits on Latex or silicone sheath that fits on penispenis

Catheter Irrigation/InstillationCatheter Irrigation/Instillation

• IrrigationIrrigation– IntermittentIntermittent– Continuous (CBI)Continuous (CBI)– PRNPRN

• InstillationInstillation– MedicationMedication

•AntisepticAntiseptic•AntibioticAntibiotic•ChemotherapyChemotherapy

Open Catheter IrrigationOpen Catheter Irrigation• Clean glovesClean gloves

• Sterile procedureSterile procedure

• Instill normal saline into bladder Instill normal saline into bladder using a 50 mL catheter tip syringeusing a 50 mL catheter tip syringe

• Catheter, syringe, and irrigant must Catheter, syringe, and irrigant must be sterilebe sterile

Closed Catheter IrrigationClosed Catheter Irrigation

• Catheter has 3 lumensCatheter has 3 lumens– Irrigant, Drainage, BalloonIrrigant, Drainage, Balloon

• Calculating urine outputCalculating urine output– Add total amount of irrigant instilledAdd total amount of irrigant instilled– Add the total amount of urine plus Add the total amount of urine plus

irrigant drained outirrigant drained out– The difference is urine outputThe difference is urine output

Nursing DiagnosisNursing Diagnosis•Functional urinary incontinenceFunctional urinary incontinence•Reflex Urinary incontinenceReflex Urinary incontinence•Stress Urinary incontinenceStress Urinary incontinence•Total Urinary incontinenceTotal Urinary incontinence•Urge Urinary incontinenceUrge Urinary incontinence•Overflow Urinary incontinenceOverflow Urinary incontinence•Urinary RetentionUrinary Retention•Risk for infectionRisk for infection•Risk for impaired skin integrityRisk for impaired skin integrity