UNIT 8.

URINARY ELIMINATION
 Introduction

• The ability to produce and eliminate waste in the form of urine is

essential for life.

• The mechanisms of glomerular filtration and the production of urine

are complex and require an integration of factors, involving effective

functioning of the kidneys, ureters, urinary bladder, and urethra.

Introduction

• In addition, elimination of urine in the male is influenced when an

enlarged prostate gland causes obstruction of the urethra.

• Knowledge of anatomy and physiology that influences urinary

elimination is the basis for understanding how to best care for clients

with urinary elimination problems.

Definition of terms
• Micturition voiding and urination all refer to the process of passing
urine.
Dysuria
• Pain and difficulty in passing urine
Hematuria
• Blood in Urine
Incontinence
• Inability to control urine
Definition of terms
• Nocturia
• Voiding two or more times at night
• Urgency
• The sudden, strong desire to void.
• Dysuria
• Voiding that is either painful/difficult
• Anuria : lack of urine production
• Crede maneuver : a technique used to void urine from the
bladder of an individual who, due to disease, cannot do so without
aid.
Definition of terms
• Urinary Incontinence/enuresis
• Involuntary leakage of urine or leakage of urine or loss of bladder
control.
• Urinary Retention
• When emptying of the bladder is impaired, urine accumulates and
the bladder becomes over distended, known as urinary retention
• Polyuria : excessive urination
• Glycosuria : Glycosuria is a condition in which a person's urine
contains more sugar, or glucose, than it should.
Urination

• Urination also called (voiding, micturition)is the act of

emptying the urinary bladder.
B. Urine characteristics

• 1. Color.
• Indicates the degree of concentration.
• Usually straw colored, pale to amber.
• 2. Clarity or turbidity.
• Usually transparent or translucent.
• Cloudiness indicates the presence of abnormal constituents.
 Continuation
• 3. Amount.
• Indicates the volume of production and excretion of urine.
• Usually 1,200 to 1,500 mL daily.
• 4. Odor.
• Is aromatic.
• Can indicate the presence of certain foods and constituents related to infection.
• 5. Specific gravity.
• Reflects the kidneys’ ability to concentrate urine.
• Usually 1.001 to 1.029.
Continuation
• 6. pH.
• Reflects the kidneys’ ability to maintain a balanced hydrogen ion
concentration in the blood.
• Usually between 4.6 and 8; average is 6.
• 7. Protein.
• Exists in molecules that generally are too large to leak into the glomerular
filtrate, but leakage can occur in the presence of glomerular damage or
impaired tubular reabsorption.
• A random urine specimen for protein more than 6 mg/dL when tested with
a dipstick indicates renal disease.
• The amount of protein in a 24-hour specimen indicates the severity of
kidney disease; an expected 24-hour result is 25 to 150 mg.
Abnormal characteristics of urine and their
implications.
Abnormal characteristics of urine and their
implications.
 Factors Affecting Urinary Function

• A. Developmental
• 1. Infants.
• a. Generally produce 8 to 10 wet diapers daily.
• b. Develop voluntary control at 18 to 24 months of age.
• 2. Children: May experience involuntary passage of urine when awake
(enuresis)or when sleeping (nocturnal enuresis).
• 3. Older adults.

• Experience a decline in urinary system function.

• Are less able to filter waste and maintain acid base and fluid

and electrolyte balance.

Continuation

• Experience a loss of bladder tone, contributing to urgency, frequency, and

incomplete emptying of the bladder.

• Older women: Experience additional weakening of pelvic floor muscles due to

childbearing and genitourinary atrophy.

• Older men: May experience an enlarged prostate, causing urine leakage,

awakening at night to void (nocturia),and urine retention

B. Psychosociocultural factors

• Lack of privacy or an unfamiliar environment may lead to an

inability to void in public (bashful bladder).

• Loss of dignity related to toileting activities in a health-care

environment, especially if the client is catheterized, can cause
emotional distress.
• Cultural influences may cause a person to insist on a caregiver of the

same gender to provide toileting assistance.

• Muslims use the left hand for toileting activities and the right hand for

eating and praying.

C. Nutrition and hydration

• As fluid intake increases, a corresponding increase in urine

output occurs; as fluid intake decreases, a corresponding
decrease in urine output occurs.
• Some substances increase urine production (e.g., coffee, tea,
cola, alcohol, and chocolate) by inhibiting the release of
antidiuretic hormone.
• Sodium intake produces water retention, causing decreased
urine production.
 D. Activity and position

• Exercise maintains detrusor and pelvic floor muscle tone, which

helps the bladder to empty completely.

• Heavy exercise can precipitate dehydration via sweating,

causing the kidneys to retain water, reducing urine output.

continuation

• Gravity assists in the flow of urine and the ability to empty the bladder
completely; typically, the sitting position is best for women and the
standing position is best for men.

• The bladder may not empty completely when on a bed pan or when
using a urinal while lying flat; the side-lying position may facilitate
urination for men who are on bedrest.
F. Physiological problems

• Problems can interfere with the production of urine; for example,

cardiovascular and metabolic disorders that reduce blood flow through
the kidneys (e.g., hypertension, heart failure, shock, and diabetes
mellitus).
• Problems can impair the nervous system that innervates the urinary
system; for example, brain attack (stroke) or spinal cord injury.
Continuation

• Problems can interfere with the flow of urine; for example, calculi and
enlargement of the prostate gland.

• Problems can cause inflammation of the structures of the urinary

system; for example, urinary tract infection (UTI).

• Impaired cognition (e.g., delirium, dementia) or a mental health

problem may alter a person’s perception of the need to void.
G. Surgical and diagnostic procedures

• Rectal, vaginal, and pubic surgery and childbirth can result in

trauma to and edema of local tissues, causing pressure on the

structures of the urinary system and loss of pelvic floor

muscle control.
• Some surgical procedures (e.g., hysterectomy, transurethral
resection of the prostate) require insertion of a temporary
indwelling urinary catheter postoperatively.
• Insertion of a fiber optic instrument (cystoscope) through the
urethra to examine the bladder (cystoscopy)can cause urethral
swelling, obstructing urinary excretion.
 H. Communication or mobility problems

• An inability to communicate the need to void can result in what

appears to others to be an episode of incontinence when in fact

the client cannot indicate personal needs to others.

• An inability to engage in toileting activities, such as
undressing, can result in episodes of urination before reaching
a toilet.
• An inability to be mobile, such as with clients who are bed-
or chair-bound, may prevent a client from obtaining
assistance in time to make it to the bathroom.
Nursing Care to Assist Clients With Urinary
Elimination
• Nursing interventions related to the urinary system involve
activities concerning the assessment of a client’s urinary
status, collection of specimens for diagnostic tests, promotion
of efficient urinary functioning, and the prevention and
treatment of urinary problems.
• Many of these interventions are independent functions of the
nurse; however, some require a primary health-care
provider’s prescription. Nurses must have a thorough
understanding of when and how to implement these
interventions.
 A. Independent nursing interventions

• 1. Assess the client’s urinary functioning and the amount and

characteristics of urinary output.

• 2. Encourage the client to follow consistent daily routines.

• 3. Encourage the client to engage in regular exercise to help

maintain pelvic floor and bladder muscle tone.
Continuation

• 4. Encourage the client to drink 8 to 10 glasses of fluid daily.

• Provide hourly goals for intake.

• Keep fluids in easy reach.

• Provide fluids that the client prefers.

 Continuation
• 5. Assist the client with toileting as soon as the need to void is indicated
by the client.

• 6. Provide privacy during toileting.

• 7. Encourage the client to void (e.g., when the urge to void is felt; on
awakening, after meals, and at bedtime; every 2 hours when awake).

• 8. Encourage the client to completely empty the bladder when voiding to

prevent urinary stasis.
 Continuation
• 9. Assist with positioning.

• Female: Sitting.

• Male: Standing or side lying.

• 10. Provide a commode at the bedside for clients who are unable to
ambulate to a bathroom.

• 11. Assist bed-bound clients to use a bedpan; remove the bedpan as soon
as the client is done voiding; provide perineal care.
Continuation

• 12. Promote urination.

• Put the client’s hands in warm water.

• Turn on a sink faucet so that the client can hear the sound of running
water.

• Pour warm water over the client’s perineum.

• Place a warm moist wash cloth over the client’s perineum.

Continuation

• Apply manual pressure over the client’s bladder (Credé

maneuver).

13. Teach the client techniques to prevent UTIs.

14. Provide nursing care for clients who are incontinent of urine.

15. Teach the client about prescribed diagnostic tests and the
interventions to self-perform in relation to various tests.
 B. Dependent nursing interventions

• 1. Implement care that prepares a client for a test that requires a

prescription (e.g., NPO, medications, enema).

• 2. Obtain urine specimens for prescribed diagnostic tests.

• 3. Insert and maintain urinary catheters as prescribed.

Continuation

• 4. Provide nursing care for clients with a urinary diversion.

• 5. Administer prescribed kidney-specific anti-infectives, urinary

antispasmodics, and estrogen; teach the client information about the

medications and self-administration of the medication regimen.

Urinary incontinence

• Urinary incontinence is the inability to control the passage of urine.

• May be acute and reversible (e.g., when due to infection or medication

side effect) or chronic and nonreversible (e.g., when due to

neurological problems, such as spinal cord injury).

Clinical manifestations.
Clinical manifestations.
Nursing care for clients with urinary
incontinence
• Independent nursing care.
• Provide perineal care immediately after voiding or on a
regular schedule.
• Encourage the use of/or apply an appropriate incontinence
device (e.g., pads, Depends, external condom catheter);
avoid the use of the word “diaper.”
• Apply an external condom catheter for a male client.

• Provide perineal care; rinse and dry thoroughly.

• Avoid lubricants or the catheter will slide off.

• Measure the circumference of the penis to ensure correct catheter size.

• Hold the penis and place the condom over and beyond the glans penis; unroll the condom the

full length of the penis, leaving 1 to 2 inches between the glans penis and drainage tubing of

the catheter.
Applying a Condom Catheter:

• Do not retract the foreskin if the client is uncircumcised.

• Secure the condom: For a condom with internal adhesive,
grasp the penis and gently compress so the entire condom
comes into contact with the penile shaft; for a condom with an
external adhesive strip, wrap the strip in a spiral along the
shaft but do not overlap the ends or use surgical tape because
these actions can act as a tourniquet.
 • Ensure that the condom is not twisted to prevent trauma
(e.g., obstruction of urine flow, irritation at meatus, skin
breakdown).
• Secure the catheter to the thigh to prevent tissue trauma.
• Encourage necessary lifestyle changes, such as cessation
of smoking, weight management, and dietary changes.
• Assess for clinical manifestations of a vaginal infection or
UTI, such as hematuria, dysuria, and vaginal irritation.
Nursing care for clients with urinary
incontinence
• Dependent nursing care.
• Apply a perineal skin barrier as per agency protocol.
• Administer medications as prescribed.
• Teach the client how to use a prescribed anti-incontinence
device (e.g., intravaginal support [pessary], penis clamp,
internal urethral meatus plug).
Continuation
• . Specific nursing care for clients with stress and/or urge
incontinence.
• Teach the client to avoid constipation: Increase fluid intake,
eat high-fiber foods, and increase activity.
• Teach the client to limit activities that increase intra-
abdominal pressure (e.g., high-impact exercises, lifting,
bending).
Continuation
• Encourage the client to perform Kegel exercises to strengthen
the pelvic floor.
• Tighten the pelvic muscles as if to stop urination or
passing of gas.
• Hold for 5 to 10 seconds and then rest 5 to 10 seconds.
• Repeat two to four times a day with 15 repetitions per
session.
• Explain to the client that it may take 6 to 12 months for
positive results.
Continuation
• Teach vaginal weight training to females if prescribed.
• Insert a small cone-shaped weight into the vagina and
contract the pelvic floor muscles to keep it in place.
• Keep the cone-shaped weight in the vagina for 15 minutes
twice a day.
• Employ a bladder retraining program, particularly for clients
with urge incontinence (e.g., using a voiding diary;
scheduling regular times for voiding; using distraction and
relaxation techniques to relax the detrusor muscle, thereby
increasing bladder capacity).
• Administer prescribed medications to relax the detrusor
muscle and increase bladder capacity (e.g., anticholinergics,
smooth-muscle relaxants, calcium channel blockers,
antidepressants) and estrogen for women who have genital
atrophy.
Continuation
• . Specific nursing care for clients with overflow incontinence.
• Identify distension of the urinary bladder: Bladder scan
indicates urinary volume; palpation reveals smooth, round,
tense mass in suprapubic area.
• Insert a single-lumen or indwelling urinary catheter if
prescribed
Continuation

• . Specific nursing care for clients with reflex incontinence.

• Precipitate urination: Stroke inner thigh, pull on pubic hair.

• Insert a single-lumen urinary catheter if prescribed.

• Administer prescribed medications to relax the urinary

sphincter such as diazepam (Valium).
Continuation

• Specific nursing care for clients with functional incontinence.

• Teach the client to schedule routine toileting, especially 15

minutes before the identified pattern of incontinence.

• Teach the client methods to facilitate toileting: Velcro clothing

closures, bedside commode or urinal, gait and strength training,
raised toilet seat, and bathroom grab bars.
Urinary retention

• Urinary retention is the accumulation of urine in the bladder due

to an inability to empty the bladder completely.

• Excessive distention of the urinary bladder impairs contractility

of the detrusor muscle, further impairing urination.

Clinical manifestations.

• Suprapubic distention.

• Reported feeling of bladder fullness and discomfort; inability

to void despite presence of urge.

• Overflow incontinence exhibited as frequent urination of

small amounts of urine.
Precipitating factors.

• Factors that cause inflammation and swelling of the genitourinary

tract (e.g., infection, childbirth, and pelvic surgery).

• Neurological problems that affect the brain, spinal cord, or

peripheral nerves (e.g., brain attack, tumors, and blunt trauma to
neuro logical tissue).

• Infection (e.g., genital herpes).

Precipitating factors.

• Obstructions (e.g., enlarged prostate, strictures, tumor, urinary calculi,

and fecal impaction).

• Medications (e.g., antihistamines, tricyclic antidepressants, beta-

adrenergic blockers, monoamine oxidase inhibitors, antispasmodics, anti-

parkinsonism medications, opioids, and anesthetic agents).

 Nursing care for a client with Urinary
retention
• Monitor I&O.
• Palpate the suprapubic area for bladder distention.
• Encourage the client to use a position that facilitates voiding by the use
of gravity.
• Provide privacy when toileting.
• Use techniques to encourage voiding (e.g., warm washcloth on
perineum,).
Continuation

• Assist the client with a warm-water bath that exposes just the
perineal area to the water (sitz bath).

• Measure postvoiding residual (e.g., catheterization with a single-

lumen tube, bladder ultrasound).

• Insert a single-lumen catheter or indwelling urinary catheter as

prescribed.
Continuation

• Provide preoperative and postoperative care for a client having

surgery to remove an obstruction, such as prostate surgery.

• Teach intermittent self-catheterization to drain the bladder for

clients with spinal cord injuries or neurological disorders.

CATHETERIZATION

ØA catheter is a tube made of vicryl or latex and is inserted

into the urinary bladder to drain urine

ØCatheterization is the process of inserting a catheter through

the urethra into the urinary bladder for drainage of urine or
instillation of drugs
TYPES OF CATHETERS

1. According to Site
a) Urinary Catheter
Inserted through the urethral meatus into the bladder
b) Supra – pubic Catheter
Inserted through an incision made at the supra – pubic area into the
bladder
It is used when there is obstruction of urethra or after urethral
operation
c) Uridom/Uricondom

It is used in male patients to cover the penis.

It is an external male catheter used in patients with urinary
incontinence
2. According to Duration

a) Straight or In and Out Catheter

ØInserted to drain urine and removed immediately and discard
b) In – dwelling/foley/retension
ØThe catheter remains in place for sometime and is anchored by an
inflated balloon inside the bladder
ØThe most commonly used of Foley's catheter which contains two
cavities, one for urinary out flow and the other for inflating the
balloon
ØOthers may have three or more cavities e.g. those used for bladder
irrigation
Purpose of catheterization
ØTo obtain urine specimen from unconscious patient
ØTo facilitate accurate measurement of urine in patients who require
strict fluid monitoring
ØTo relieve urine retention
ØTo measure urine residue
ØTo perform bladder washout
ØWomen with full bladder during 1st and 2nd stages of labor
ØPre and post abdominal or pelvic surgery
ØUrinary incontinence
Complications of Catheterization

ØInfection
ØPsychological trauma
ØPhysical trauma
ØDiscomfort
ØUrine incontinence
ØRenal failure incase of catheter blockage
Nursing care for clients with an indwelling
urinary catheter
• Monitor I&O.
• Monitor urine characteristics.
• Assess the perineal area for clinical manifestations of an
infection of skin and mucous membranes.
• Assess for clinical manifestations of a UTI.
Continuation

• Keep the collection bag below the level of the bladder by attaching it to the
bed frame and coiling the tubing on the bed to prevent dependent loops.

• Maintain a closed system to prevent the introduction of pathogens by

maintaining the integrity of all connections; if the tubing becomes
disconnected, wipe both ends of the tubing with an antiseptic solution
before reconnecting them.
 Continuation
• Secure the tubing to the client’s anterior thigh for females and lower
abdomen in males; this limits tension on tubing and helps to prevent
lying on the tubing.

• Wash the perineal area and around and down the catheter with mild
soap and water and rinse and dry thoroughly every 8 hours; avoid
using powders and lotions after perineal care because these products
provide a medium for the growth of microorganisms.
Continuation

• Encourage ambulation and the upright position to facilitate

bladder emptying if permitted.

• Encourage the intake of 3 L of fluid daily, if permitted, to

help flush the urinary tract.
Continuation
• Encourage the intake of foods that increase urine acidity (e.g.,
cranberry juice, eggs, meat, poultry, whole grains, plums, prunes, and
tomatoes); acidic urine discourages the growth of microorganisms.
• Discourage the intake of foods that increase urine alkalinity (e.g.,
most fruits, vegetables, legumes, milk, and milk products); alkaline
urine favors the growth of microorganisms.
Continuation
• Maintain aseptic technique when emptying the collection bag
(e.g., keep the drainage bag off the floor; ensure the spout
does not touch the collection graduate or floor).
• Teach the client the importance of meticulous perineal care
after a bowel movement.
• Administer a prescribed oral or intravenous antibiotic and a
prescribed topical antibiotic or antifungal ointment to the
perineal area.
Nursing care to prevent obstruction of the
catheter.

• Ensure the catheter has no mechanical obstructions (e.g.,

kinks in the tubing, client lying on the tubing).
• Monitor the patency of the tubing every 2 hours, especially if
sediment or hematuria is present.
• Ensure that if a clamp is used during a procedure that it is
removed promptly after the procedure (e.g., obtaining a urine
specimen, instilling a medication into the bladder for a
prescribed time frame).
Continuation

• Instill or irrigate the catheter with sterile normal saline

solution as prescribed, especially if the client’s urine has
blood clots or large amounts of sediment.

• Change the catheter if drainage is impaired