1. Urinary Elimination

2. The term elimination is defined as the excretion of waste products.
Concept: Elimination
Definition:
The term elimination is defined as the excretion of waste products.
Bowel Elimination
Bowel elimination is defined as the passage of stool through the intestinal tract and dispelling the stool by means of intestinal smooth muscle contraction.
Urinary Elimination
Urinary elimination is defined as the passage of urine through the urinary tract by means of the urinary sphincter and urethra.

3. Risk Factors for Problems of Elimination
Conditions that result in
Neurologic impairment (Neurogenic bladder)
Trauma to the brain or spinal cord
CVA
Diabetic neuropathy (R/T metabolic derangements)
Altered mobility
Severe arthritis
Cognitive impairment
dementia
Immunologic impairment or infection
AIDS

4. Scientific Knowledge Base: Organs of Urinary Elimination
Kidneys
Remove waste from the blood to form urine
Ureters
Transport urine from the kidneys to the bladder
Bladder
Reservoir for urine until the urge to urinate develops
Urethra
Urine travels from the bladder and exits through the urethral meatus.

5. Urinary System
Urinary System Organs
Renal Nephron

6. Additional Kidney Functions
Production of erythropoietin is essential to maintaining a normal red blood cell (RBC) volume.
Erythropoietin stimulates bone marrow to produce RBCs and prolongs the life of mature RBCs.
Production of renin.
Renin starts a chain of events that cause water retention, thereby increasing blood volume.
Kidneys affect calcium and phosphate regulation

7. Renin-Angiotensin Mechanism

8. Kidneys affect calcium and phosphate regulation
Vitamin D
The Kidneys produces a substance that converts vitamin D into its active form.
Intestines absorb more Ca from foods.

9. Factors Influencing Urination
Disease conditions
Socioeconomic factors (need for privacy)
Psychological factors (anxiety, stress, privacy)
Fluid balance
Nocturia, polyuria, oliguria, anuria
Diuresis
Fever
Medications and medical procedures

10. Disease Conditions Affecting Urination
Prerenal, renal, postrenal classification
Conditions of the lower urinary tract
Diabetes mellitus and neuromuscular diseases such as multiple sclerosis
Benign prostatic hyperplasia
Cognitive impairments (e.g., Alzheimer’s)
Diseases that slow or hinder physical activity
Conditions that make it difficult to reach and use toilet facilities
End-stage renal disease, uremic syndrome

11. Pre-renal, renal, post-renal classification
Decrease blood flow
Condition of renal tissue
Obstruction in the UT that prevents flow from kidneys

12. Conditions of the Lower Urinary Tract

13. Diabetes Mellitus and Neuromuscular Diseases

14. Benign Prostatic Hyperplasia (BPH)

15. Conditions Affecting Urination
Conditions that make it difficult to reach and use toilet facilities
Cognitive impairments
Diseases that slow or hinder physical activity

16. End Stage Renal Disease (ESRD) (CKD)

17. Dialysis
Renal Replacement
Two methods
Peritoneal
Hemodialysis

18. Indications for Dialysis
Renal failure that can no longer be controlled by conservative management (Conservative management would include dietary modifications and the administration of medications to correct electrolyte abnormalities.)
Worsening of uremic syndrome associated with ESRD,
which would include nausea, vomiting, neurological changes, and pericarditis)
Severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures (These abnormalities would include hyperkalemia and pulmonary edema.) by simpler measures

19. Factors Influencing Urination
Disease conditions
Socioeconomic factors
Need for privacy
Cultural differences
Psychological factors
Anxiety
Emotional Stress
Privacy

20. Factors Influencing Urination
Fluid balance
Nocturia, polyuria, oliguria, anuria
Diuresis
Fever
Foods
Medications and medical procedures

21. Fluid Balance Symptoms common to urinary disturbances include
frequency
urgency
dysuria
polyuria
oliguria
incontinence
difficulty in starting the urinary stream.

22. Medications and Medical Procedures
Surgery (stress)

23. Alterations in Urinary Elimination
Urinary retention
An accumulation of urine due to the inability of the bladder to empty
Urinary tract infection
Results from catheterization or procedure
Urinary incontinence
Involuntary leakage of urine
Urinary diversion
Diversion of urine to external source

24. An accumulation of urine due to the inability of the bladder to empty
Urinary Retention
An accumulation of urine due to the inability of the bladder to empty
Signs and Symptoms
Bladder distention
No UO in several hours
May void small amounts of urine 2-3 times an hour
Treatment
Residual urine
Bladder scan
I & O catheter

25. Urinary Tract Infection
Results from catheterization or procedure
CAUTIs
(Catheter-associated UTIs)
Increased hospitalization
Increased morbidity and mortality
Longer hospital stay
Increased hospital cost

26. Urinary Tract Infection
7 reasons for insertion of a Foley Catheter
Urinary retention
To relieve urinary obstruction
Accurate I&O in critical patients
Bladder decompression for surgery
Urinary incontinence with stage 3 – 4 pressure ulcers
Comfort for terminal patient
Urological procedurss

27. Urinary Tract Infection
Signs and symptoms
Pain or burning during urination (dysuria)
Fever, chills, nausea, vomiting, and malaise
Frequent and urgent sensation of need to void
Blood-tinged urine (hematuria)
Treatment
Medication

28. Urinary incontinence
CVA, Heat injury, spinal cord injury, diabetic neuropathy, irritating factors

29. Nursing Diagnoses
Impaired Social Interaction r/t Loss of independence: clothing becomes wet with urine and odor.
Impaired body image r/t incontinent of urine.
Risk for impaired skin integrity.

30. Nursing Knowledge Base & Assessment
Infection control and hygiene
Growth and development
Muscle tone
Psychosocial considerations
Cultural considerations

31. Physical Assessment
Gather nursing history for the patient’s urination pattern and symptoms, and factors affecting urination.
Conduct physical assessment of the patient’s body systems potentially affected by urinary change.
Assess characteristics of urine.
Assess the patient’s perception of urinary problems as it affects self-concept and sexuality.
Gather relevant laboratory and diagnostic test data.

32. Physical Assessment Skin and mucosal membranes Kidneys Bladder
Assess hydration.
Kidneys
Flank pain may occur with infection or inflammation.
Bladder
Distended bladder rises above symphysis pubis.
Urethral meatus
Observe for discharge, inflammation, and lesions.

33. Assessment of Urine Intake and output (I&O) Characteristics of urine
Color
Pale-straw to amber color
Clarity
Transparent unless pathology is present
Odor
Ammonia in nature
Urine testing
Specimen collection

34. Urine Tests and Diagnostic Examinations
Urinalysis
Specific gravity
Culture
Noninvasive procedures
Invasive procedures

35. Catheterization Catheter insertion Closed drainage systems
Catheter care
Perineal hygiene
Fluid intake
Catheter irrigations and instillations
Removal of indwelling catheter
Alternative to urethral catheterization

36. Types of Urinary Catheters
Intermittent and indwelling retention catheterizations are the two forms of catheter insertion.
With the intermittent technique, you introduce a straight single-use catheter (A) long enough to drain the bladder (5 to 10 minutes). When the bladder is empty, you immediately withdraw the catheter. You can repeat intermittent catheterization as necessary, but each catheter insertion increases risks of trauma and infection.
It is common for people with spinal cord injury or other neurological problems such as multiple sclerosis to perform self–intermittent catheterization up to every 4 hours daily for months or years. If done correctly with the use of clean technique, they frequently do not experience more UTIs; in fact, the UTI rate is lower than for patients with long-term indwelling catheters.
An indwelling or Foley catheter (B) remains in place for a longer period—until a patient is able to void voluntarily, or until continuous accurate urine measurements are no longer needed.
A second type of intermittent catheter has a curved tip. A Coudé catheter is used on male patients who may have enlarged prostates that partially obstruct the urethra. It is less traumatic during insertion because it is stiffer and easier to control than the straight-tip catheter.
Catheters are available in many diameters to fit the size of a patient’s urethral canal.
[Box 45-8 on text p provides suggestions for how to make appropriate decisions regarding catheter selection.]
[Shown is Figure from text p ]

37. Urinary Drainage System and Infectious Organisms

38. Applying a Condom Catheter
The condom catheter is suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying.
The condom is a soft, pliable, latex sheath that slips over the penis.
Patients wear it only at night or continuously, depending on their needs.
After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP).
Be sensitive to the privacy needs of patients.
Be sure that the skin of the penile shaft is intact and free from swelling, redness, or open lesions before applying the condom catheter.
Ask for assistance if the NAP is uncertain how to apply the adhesive strip that secures the condom catheter.
[Image shows the distance between the end of the penis and the tip of the condom = Step 12 on text p Box Procedural Guidelines: Applying a Condom Catheter.]
[See Box Procedural Guidelines: Applying a Condom Catheter on text p ]
Three general methods may be used to secure a condom catheter:
1. The first method uses a strip of elastic tape or rubber that encircles the top of the condom to secure it in place.
2. Another type uses a self-adhesive condom sheath.
3. The third method uses an inflatable ring within the condom to secure placement.
Take care to ensure that, whatever type or size is used, blood supply to the penis is not impaired. Never use standard adhesive tape to secure a condom catheter because it does not expand with change in penis size and is painful to remove. After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP).
[Image shows the application of elastic tape in a spiral fashion to secure condom catheter to penis = Step 13a on text p. 1065, Box Procedural Guidelines: Applying a Condom Catheter.]

39. Applying a Condom Catheter (cont’d)

40. External Urinary Device

41. Restorative Care Strengthening pelvic floor muscles Bladder retraining
Habit training
Self-catheterization
Maintenance of skin integrity
Promotion of comfort