Kozier Ch 48 Urinary Elimination

• •Regulation of Fluid and Electrolytes
• •Regulation of Acid-Base
• •Hormones
• –Erythropoietin- stimulates RBC production
• –Renin
• •Substance that converts Vit D to
• active form for Calcium absorption

• –Kidneys
• •nephron

• –Ureters
• –Bladder
• –Urethra
• –Pelvic floor
• –Urination

• •Regulation of Fluid and Electrolytes
• •Regulation of Acid-Base
• •Hormones
• –Erythropoietin- stimulates RBC production
• –Renin
• •Substance that converts Vit D to active form for Calcium absorption

• •Nephrons-
• –Filter blood & remove metabolic wastes
• –Plasma proteins & blood cells too large to cross
• membrane
• •Na & water excretion/retention regulated by ADH & aldosterone
• •Normal Urine Output 1500-1600/day & 30 ml /hour

• •Ureters
• –Connects kidneys to bladder (10-12 in long, small (0.5 in) diameter
• –Flap prevents reflux

• •Bladder- reservoir
• –Muscles allow for wall of bladder to expand & fill
• & release urine
• –Bladder can hold 300-600 ml of urine

• •Urethra
• –From bladder to urinary meatus
• –Shorter in women (1.5 in) than men (8 in)

• •Pelvic floor
• –Muscles in abdomen provide a sling like structure holding bladder in place
• –Sphincters allow urine to be held or passed

• •Urination (micturation, voiding)
• –Process of emptying the bladder
• –Awareness of urine in bladder is when 250-450 ml urine stimulates sensory nerves
• –Awareness to void based on:
• •Intact nervous system
• •Ability to sense a full bladder

• •Normal urinary output
• –average 1500 mL/24 hr (60 mL/hr )
• –should be no less than 30mL/hr
• –Most people void 5-6 times/day

• •Normal process
• What is involved
• –Bladder fills & stretches
• (unfolds upward)
• –Impulses sent to spinal cord
• –Inner sphincter opens
• –Sensation of “Need to void”
• –Voluntary urination

• •Ability to micturate (control urination)
• –18 – 24 months old

• •Aging impairs micturition
• –Disease processes
• •Reaching toilet
• •Balance
• •Unable to get up from toilet

• Older Adults: Lifespan considerations P. 1289
• –Kidney function decreases
• –Urgency and frequency common
• •Men- enlarged prostate
• •Women- weakened muscles supporting bladder & weakness of sphincter
• –Capacity of bladder less:
• •Incomplete emptying
• •Nocturia - getting up to void more than twice a night

• •Psychosocial- factors that cause an inability to relax
• –Privacy, normal position, not enough time

• •Fluid & food-
• –Intake of fluids
• –Caffeine-increased diuresis
• –Alcohol-inhibits release of ADH
• –Urine color- beets turn urine red

• •Medications- list on 1290
• –Diuretics increase urine output
• –Anticholinergics- inhibit free flow of urine
• –Nephrotoxic (damage to the kidney)
• –Meds turn urine color- pyridium (used for bladder spasms from UTI) turns urine orange

• •Surgical procedures:
• – of reproductive & urinary tract can affect ability to pass urine
• –Stress triggers release of ADH & increase in aldosterone
• –Anesthetics:
• •decrease BP & glomerular filtration decrease awareness to void

• Pathological Conditions:
• •Renal failure
• •Bladder/kidney infections
• •Kidney stones
• •Hypertrophy of the prostate
• •Decreased blood flow through glomeruli
• –Heart failure
• •Altered cognition
• •Mobility problems
• •Neurological conditions- MS, diabetes
• •Communication problems

• •Nursing History
• –Elimination patterns
• •Daily voiding patterns
• •Frequency and times
• •Volume and appearance
• •Nighttime voiding

• •History:
• Ask about Factors associated with Altered Urinary Elimination - such as:
• •Polyuria - excessive amount of urine (diabeties insipidus)
• •Oliguria - not voiding enough
• anuria - not voiding at all
• •Frequency - more than 4 - 6 times a day
• •Nocturia - two or more times a night
• •Urgency - sudden strong desire to void
• •Dysuria - painful urination
• •Incontinence - cant hold it
• •Hesitancy - going & stopping - cant empty bladder
• •Retention - not totally emptying bladder

• •History: ask about-
• •Fluid intake
• •Prior history of renal stones
• •History of urinary track infections (UTIs)
• •Bladder/kidney surgery
• •Medication use
• •Other diseases/conditions affecting urination

• •Physical Assessment:
• –Percussion of kidneys
• –Palpation & percussion of bladder
• –Inspect urinary meatus
• –Look & smell for urine
• –Check skin- general color & texture, local irritation
• –Check for edema

• •Assessment of Urine
• –Measure fluid intake and output (I/O)
• –Observe universal precautions
• –Residual urine (less than 100 mL after voiding)

• •Characteristics of urine
• –Color (pale, straw, amber) & clarity
• –Odor, more concentrated, stronger odor
• –Sterile - urine normally sterile
• –pH- usually acidic 4.5 - 8
• Specific gravity- 1.010-1.025
• –No presence of glucose, ketones, or blood

• Urine Collection
• •Voided urine – ambulatory patients who go to bathroom put specimen “hat” over toilet & instruct pt.
• •Midstream clean catch – cleanses perineal area with towelette front to back, starts urinating then goes into specimen cup
• *less than 10,000 organisms & multiple orgainsms = contamination from skin - not treated
• •Sterile – catheterize or remove sample from indwelling catheter by accessing port on indwelling
• catheter
• •24 hour urine- to begin have pt void and record the
• time. Collect all urine from this time

• •Diagnostic Tests:
• –Urinalysis–“dipstick”, measures pH, specific gravity, protein glucose
• –Urinalysis- sent to lab to assess characteristics of urine (Sp.Gr.)
• –Urine Culture (sterile specimen)
• –Blood tests- assesses renal function
• •BUN (8-20 mg/dl)
• •Creatinine (0.5-1.1mg/dl)
• *if creatinine is normal but BUN is up - dehydrated - need to be better hydrated)

• Main one:
• •Impaired urinary elimination

• •Many types of Urinary Incontinence
• –Functional - cant get to bathroom (broken leg)
• –Reflex - when specific volume is in the bladder
• –Stress - sudden abd pressure -sneeze or cough
• –Urge - sudden strong urge to void
• –Total (continuous & unpredictable passage of urine)

• •Urinary retention
• •Risk for infection
• •Low self-esteem
• •Risk for impaired skin integrity
• •Body image disturbance
• •Self-care deficit, toileting
• •FVD or FVE
• •Lack of knowledge
• •Risk for social isolation

• •Goals and expected outcomes. Client will:
• –Maintain or restore a normal voiding pattern
• –Remain dry throughout night
• –Will have intact skin
• –Will not develop an infection

• •Promote fluid intake
• –1500 ml/day, more if UTI or fluid loss
• •Maintain normal voiding habits (Guidelines p. 1299)
• –Positioning: normal position, commodes
• –Relaxation: privacy, allow time, run water
• –Timing: avoid delays, establish pattern
• –Confined to bed: warm bedpan, high-fowlers
• •Assist with toileting

• RISKS
• •Women > men
• •E.Coli
• •Indwelling catheters
• •Wiping back to front
• •Holding urine too long
• •Synthetic undies & hose
• •Tight clothing
• •People with diabetes
• •Intercourse
• •Baths & soaps

• •S & S - signs & symptoms
• •Frequency
• •Urgency
• •Burning, pain (dysuria)
• ** elderly may not experience dysuria - if they experience shaky chills with no other symptoms - probably
• •Cloudy urine (WBCs)
• •Blood in urine (hematuria)

• •½ of 1.5 million Americans who live in nursing homes are incontinent
• •Incontinence is not a normal change with aging
• •Risk factors:
• –Men (BPH - benign prostetic hypertrophy - enlarged prostrate), Women (childbirth)
• –Obesity, diabetes

• •Types
• •Functional – usually continent person can’t reach toilet on time
• **Confusion, dementia, depression
• **Impaired mobility
• **Sedation or diuretic therapy

• •Reflex- when specific bladder fullness is reached
• **Enlarged prostate
• **Spinal cord injury

• •Stress- due to increased intra-abdominal pressure
• **Laughing, coughing
• **Weak perineal muscles (pregnancies)

• •Urge- soon after strong urge to void
• **CVA, Parkinson’s, perineal weakness

Continence (Bladder) training

• –Bladder Training: goal is for pt. to hold greater volumes of urine & increase interval between voidings. Initially void every 2 hours then increase to every 4-6 hrs.
• Teach distraction & relaxation strategies

–Habit training or scheduled voiding: involves timed voiding. To keep dry, have ct. void at regular intervals

• Strengthening Pelvic Floor Muscles
• •Kegel exercise

•Maintain Skin Integrity: keep dry, barrier creams

•Anti-incontinence devices: pessary or intravaginal support device, condom catheters (men), indwelling catheter (used as last resort)

•Medications: Estrogen, anticholinergics (oxybutynin ER [Ditropan XL])- decreases urgency & frequency by blocking receptors in detrusor muscle of bladder thereby decreases contracts of urine & increases urine storage.

•Surgical: bladder suspension, prostate resection

• •Causes:
• –Obstruction – stones, fecal impaction, scar tissue
• –Inflammation & swelling from infection or surgery
• –Lack of innervation to bladder
• –Medications, anesthesia

• –Confirmed by:
• –Bladder scan, straight cath (post void residual >100 ml)

• •Management:
• –Assess for risk factors such as prostatic hypertrophy, medications with anticholinergic effects (valium, benadryl)
• –I & O
• –Assess for small amounts of urine voided 2-3 times/hour
• –Palpate bladder for distention
• –Place in normal voiding position, run water, Crede’s manuever (if ordered)

• •Insertion of a tube into the bladder to remove urine.
• •Only do when necessary
• •Danger is infection

• •Straight catheterization
• •Clean intermittent Self Cath (CISC)
• •Condom catheters- external
• •Indwelling catheter
• –Urethral
• –Suprapublic

• •Bladder irrigations- picture
• p. 1312
• •Urinary Diversions- surgical opening for elimination of urine . Healthy stoma is pink to brick red.

• •Insert with aseptic technique
• •Prevent UTI by keeping drainage tube and collection bag a closed system
• •Empty bag every 8 hours & before transport
• •Maintain free flow of urine
• •Provide catheter care by cleaning catheter with washcloth using soap water in downward motion
• •Provide perineal hygiene and secure tubing to the leg
• •Increase fluids to 3000 ml/day
• •Diet- acidify urine to decrease chance of UTI (eggs, cheese, meat, poultry, whole grains, cranberries,
• plums, prunes

• •Indwelling catheter removal
• –Deflate balloon!
• –May leak until gains control
• –1st void may be difficult. Assess in few hours
• –If have not voided may need a bladder scan

• •Did the client:
• –maintain or restore a normal voiding pattern
• –remain dry throughout night
• –have intact skin
• –develop an infection
• •Were the interventions appropriate? Are scheduled toileting times appropriate? Is access to toilet a problem? Are mobility aids needed:
• BSC, walker, elevated toilet seat, grab bars.
• Taking a diuretic, should continence aids like condom catheter, or absorbant pads be considered or used?

• 1. Ensure that there are no obstrucitons in the drainage
• 2. Check for tension on the tubing and if secured to thigh and fastened to clothes
• 3. Ensure that gravity drainage is maintained
• 4. Ensure that the drainage system is well sealed or closed
• 5. Observe flow of urine q 2-3 hrs & note color, odor, and abnormal constituents