1. Urinary Elimination Teresa V. Hurley, MSN, RN

2. Urinary System Kidneys filter nitrogen, metabolic wastes, excess ions and water Kidneys filter nitrogen, metabolic wastes, excess ions and water Urine produced at a rate of 60 mL/hour Urine produced at a rate of 60 mL/hour Bladder stores average 500 mL or more Bladder stores average 500 mL or more Void: detrusor muscle contracts and urine is pushed through internal urethral sphincter into urethra

3. Urinalysis Urine: clear, yellow, aromatic, without pathogens or parasites Urine: clear, yellow, aromatic, without pathogens or parasites Specific Gravity: 1.025 (concentrate urine) Specific Gravity: 1.025 (concentrate urine) Increases with dehydration Increases with dehydration Decreases with increased fluid intake Decreases with increased fluid intake

4. Urinalysis Abnormal Abnormal Protein: renal disease, 2 nd to exercise and stress Protein: renal disease, 2 nd to exercise and stress Glucose: elevated BS; diabetes Glucose: elevated BS; diabetes Ketones: CHO metabolism Ketones: CHO metabolism Diabetes, fever, fasting, starvation, high protein intake, vomiting, post-op Diabetes, fever, fasting, starvation, high protein intake, vomiting, post-op Hemoglobin: UTI, nephritis, trauma, lithiasis, hemolytic rx Hemoglobin: UTI, nephritis, trauma, lithiasis, hemolytic rx Bilirubin: liver disease Bilirubin: liver disease Urobilinogem: cirrhosis, heart failure, pernicious anemia, mono Urobilinogem: cirrhosis, heart failure, pernicious anemia, mono Nitrates: bacteria Nitrates: bacteria Leukocyte esterase: bacteria, fungal, parasitic, tumor, nephritis Leukocyte esterase: bacteria, fungal, parasitic, tumor, nephritis

5. Hematological Hematological BUN 8-16 mg/dL (end product protein metabolism) Creatinine 0.6-1.2mg/dL (muscle metabolism of creatin) Increased: renal failure, infection, obstruction, dehydration, increase protein intake, TPN Increased: renal failure, infection, obstruction, dehydration, increase protein intake, TPN Decreased: liver disease, decrease protein intake Decreased: liver disease, decrease protein intake

6. Factors Affecting Micturition Developmental considerations Developmental considerations Food and fluid intake Food and fluid intake Psychological variables Psychological variables Activity and muscle tone Activity and muscle tone Pathologic conditions Pathologic conditions Medication Medication

7. Developmental Considerations Children Children Toilet training 18 to 24 months, enuresis Toilet training 18 to 24 months, enuresis Effects of aging Effects of aging Nocturia, increased frequency, urine retention and stasis, voluntary control affected by physical problems Nocturia, increased frequency, urine retention and stasis, voluntary control affected by physical problems

8. Effects of Medications on Urine Production and Elimination Diuretics — prevent reabsorption of water and certain electrolytes in tubules Diuretics — prevent reabsorption of water and certain electrolytes in tubules Cholingeric medications — stimulate contraction of detrusor muscle, producing urination Cholingeric medications — stimulate contraction of detrusor muscle, producing urination Analgesics and tranquilizers — suppress CNS diminish effectiveness of neural reflex

9. Medications Affecting Color of Urine Anticoagulants — red color Anticoagulants — red color Diuretics — lighten urine to pale yellow Diuretics — lighten urine to pale yellow Pyridium — orange to orange-red urine Pyridium — orange to orange-red urine Elavil — green or blue-green Elavil — green or blue-green Levodopa — brown or black Levodopa — brown or black

10. Using the Nursing Process Assessing data about voiding patterns, habits, past history of problems Assessing data about voiding patterns, habits, past history of problems Physical examination of urinary system, skin hydration, urine Physical examination of urinary system, skin hydration, urine Correlation of these findings with results of procedures and diagnostic tests Correlation of these findings with results of procedures and diagnostic tests

11. Assessing a Problem With Voiding Explore its duration, severity, and precipitating factors. Explore its duration, severity, and precipitating factors. Note client’s perception of the problem. Note client’s perception of the problem. Check adequacy of client’s self-care behaviors. Check adequacy of client’s self-care behaviors.

12. Physical Assessment of Urinary Functioning Kidneys — check for costovertebral tenderness Kidneys — check for costovertebral tenderness Urinary bladder — palpate and percuss the bladder or use bedside scanner Urinary bladder — palpate and percuss the bladder or use bedside scanner Urethral meatus — inspect for signs of infection, discharge, or odor Skin — assess for color, texture, turgor, and excretion of wastes Urine — assess for color, odor, clarity, and sediment

13. Measuring Urine Output Ask client to void into bedpan, urinal, or specimen container in bed or bathroom. Ask client to void into bedpan, urinal, or specimen container in bed or bathroom. Pour urine into appropriate measuring device. Pour urine into appropriate measuring device. Place calibrated container on flat surface and read at eye level. Note amount of urine voided and record on appropriate form. Discard urine in toilet unless specimen is needed.

14. Urine Specimens Routine urinalysis Routine urinalysis Specimens from infants and children Specimens from infants and children Clean-catch or midstream specimens Clean-catch or midstream specimens Sterile specimens from indwelling catheter Sterile specimens from indwelling catheter 24-hour urine specimen 24-hour urine specimen

15. Promoting Urination Maintaining voiding habits Maintaining voiding habits Promoting fluid intake Promoting fluid intake Strengthening muscle tone Strengthening muscle tone Kegel Exercises (PFME) to Tx stress, urge mixed Kegel Exercises (PFME) to Tx stress, urge mixed Imagine voiding, stop flow, tighten rectal muscles Imagine voiding, stop flow, tighten rectal muscles Hold 5-10sec and rest 5-10sec Hold 5-10sec and rest 5-10sec Daily 40-60 PFME doing 2-4 sets of 15 each time Daily 40-60 PFME doing 2-4 sets of 15 each time

16. Client’s at Risk for UTIs Sexually active women Sexually active women Postmenopausal women Postmenopausal women Individuals with indwelling urinary catheter Individuals with indwelling urinary catheter Individual with diabetes mellitus Individual with diabetes mellitus Elderly people Elderly people

17. Four Types of Urinary Incontinence Stress — increase in intraabdominal pressure Stress — increase in intraabdominal pressure Urge — urine lost during abrupt and strong desire to void Urge — urine lost during abrupt and strong desire to void Mixed — symptoms of urge and stress incontinence present Mixed — symptoms of urge and stress incontinence present Overflow — overdistention and overflow of bladder Overflow — overdistention and overflow of bladder Functional — caused by factors outside the urinary tract Functional — caused by factors outside the urinary tract

18. Client Education for Urinary Diversion Explain reason for diversion and rationale for treatment Explain reason for diversion and rationale for treatment Demonstrate effective self-care behaviors Demonstrate effective self-care behaviors Describe follow-up care and support resources Describe follow-up care and support resources Report where supplies may be obtained in community Report where supplies may be obtained in community Verbalize related fears and concerns Verbalize related fears and concerns Demonstrate a positive body image Demonstrate a positive body image

19. Evaluating Effectiveness of Plan Maintain fluid, electrolyte, and acid-base balance Maintain fluid, electrolyte, and acid-base balance Empty bladder completely at regular intervals with no discomfort Empty bladder completely at regular intervals with no discomfort Provide care for urinary diversion and when to notify physician Provide care for urinary diversion and when to notify physician Develop a plan to modify factors contributing to problem Develop a plan to modify factors contributing to problem Correct unhealthy urinary habits Correct unhealthy urinary habits

20. Hazards of Catheterization UTI. UTI. Sepsis. Sepsis. Trauma- specially in men. Trauma- specially in men. DO NOT USE FORCE! USE STERILE ASEPTIC TECHNIQUE! Research clean technique can be used for self catheterization at home.

21. Reasons for Catheterization Relieving urinary retention. Relieving urinary retention. Obtaining a sterile urine specimen.. Obtaining a sterile urine specimen.. Emptying the bladder Emptying the bladder before, before, during, during, after surgery or diagnostic procedures. after surgery or diagnostic procedures. Monitoring of critically ill patients. Monitoring of critically ill patients.

22. Types of Catheters Indwelling catheter remains in place for continuous drainage. Intermittent catheter used to drain bladder for short periods of time. Suprapubic catheter inserted surgically above the pubic bone for continuous drainage.

24. Urinary Diversions Ureterostomy Ureterostomy Bladder is removed Bladder is removed One or both ureters redirected from kidney through the abdominal wall One or both ureters redirected from kidney through the abdominal wall

26. Ileal Conduit Bladder removed and small intestine (ileum) used as conduit between ureters and skin surface. Urine collects continuously Bladder removed and small intestine (ileum) used as conduit between ureters and skin surface. Urine collects continuously

27. Client Care Goals: Interventions Indwelling Catheter Prevent UTI (meatus burning, cloudy, foul, chills, fever) Prevent UTI (meatus burning, cloudy, foul, chills, fever) Maintain closed system Maintain closed system Cleanse catheter soap/H2O; pat dry Cleanse catheter soap/H2O; pat dry Alcohol swab for contamination Alcohol swab for contamination Empty bag q 8 h or more Empty bag q 8 h or more Bag below bladder level Bag below bladder level Maintain urine acidity: cranberry juice, prunes, plums, tomatoes, eggs,meat, cheese, citrus fruits Maintain urine acidity: cranberry juice, prunes, plums, tomatoes, eggs,meat, cheese, citrus fruits Change only sediment collects, sandy particles, trouble draining Change only sediment collects, sandy particles, trouble draining Maintain Urine Flow ( prevent urinary stasis and backflow) Maintain Urine Flow ( prevent urinary stasis and backflow) Gravity drainage Gravity drainage Check for kinks, coils, lying on tube Check for kinks, coils, lying on tube Clamp if higher than bladder Clamp if higher than bladder Do not allow on floor Do not allow on floor

28. Client Goals Prevent Infection Transmission Prevent Infection Transmission Wash hands before and after Wash hands before and after Wear gloves Wear gloves Promote Urine Production (pathogen flushing; tube irrigation; prevents stasis) Promote Urine Production (pathogen flushing; tube irrigation; prevents stasis) Oral intake 8-10 glasses (3000 mL/day) unless contra- indicated Oral intake 8-10 glasses (3000 mL/day) unless contra- indicated Parenteral or Enteral feedings Parenteral or Enteral feedings Monitor I & O q 8 h Monitor I & O q 8 h Check for blood, sediments, color, odor Check for blood, sediments, color, odor

29. Client Goals Maintain Skin and Mucosal Integrity Maintain Skin and Mucosal Integrity Prevent fecal and encrustation to catheter and perineal area Prevent fecal and encrustation to catheter and perineal area Cleasnse: soap/H2O Cleasnse: soap/H2O Sandy particle encrustation at the meatus (catheter change) Sandy particle encrustation at the meatus (catheter change)