Urinary Elimination

Anatomy and Physiology

Kidneys

  • Functional unit is the nephron; remove waster products from blood and regulate fluid and electrolyte balance
  • Glomerulus is a cluster of capillaries where the blood is filtered and urine is formed.
  • Protein does not normally filter through, so proteinuria indicates a problem.

______connect kidney to bladder

Bladder is a reservoir for urine

Urethra connects bladder to urethral meatus; the external urethral sphincter permits voluntary flow of urine

Factors Influencing Voiding

Growth and Development

  • Children cannot control urination until 18-24 months
  • Nocturnal enuresis (is a problem if > 6 yrs old)
  • Elders: impaired mobility affects toileting

Sociocultural: privacy and social expectations

Psychological: Anxiety and stress

Personal habits: privacy and adequate time

Positioning! Men should stand if possible and women should be in High Fowler’s if using bedpan

Muscle tone: Weak abdominal and pelvic floor muscles cause incontinence

  • Indwelling catheter causes loss of bladder tone

Food and fluids

  • Caffeine/Alcohol: mild diuretics
  • Sodium: fluid retention

Pathologic conditions: diabetes, MS, stroke, heart and renal failure, spinal cord injuries

Surgery: anesthetics and narcotics can cause retention

Meds:

  • Diuretics increase output (Lasix, HCTZ); Important teaching: if ordered BID, take by 3pm to avoid nocturia
  • Some change color of urine (Pyridium->orange urine)

Terms Used

Polyuria: void in abnormally lg amts

  • Ex: Diabetes: polyuria, polydipsia, polyphagia

Oliguria: Low urine output

  • R/T Decreased fluids or impending renal failure

Anuria: No urine output

Dialysis: mechanism of filtering blood r/t kidney failure

  • Hemodialysis and Peritoneal dialysis

Frequency: more than usual

Nocturia (2 or more per night)

Urgency: feeling of need to void

Dysuria: painful or difficult

Hematuria: blood present

Enuresis: Involuntary urination after age 4

Urinary Incontinence: Symptom, not disease; can have significant impact on life. Two types:

  • Stress Incontinence: Leaking on coughing, laughing, sneezing, jumping
  • Urge Incontinence: Unable to retain urine long enough after urge is felt
  • Potential complication: ______

Common Urinary Elimination Problems

Urinary Retention: Unable to completely empty bladder -> urine accumulates-> bladder becomes distended -> risk for UTI and incontinence

  • Potential Causes of retention: prostate gland enlargement; fecal impaction; pregnancy; anesthesia
  • Can assess post-void residual with bladder scan or straight catheterization; >400ml is abnormal

Urinary Tract Infections

  • =40% of nosocomial infections, most due to non-asceptic catheterization; urosepsis is a life threatening complication; good handwashing and sterile technique during catheterization is essential
  • Most common bacteria: E. coli (from colon)
  • Causes: poor perineal hygiene; frequent sexual intercourse; bubble baths; residual urine
  • Common symptoms: dysuria, urgency, frequency, hematuria
  • If spreads to kidneys: fever, flank pain, chills
  • Older adult may only show change in mental status
  • Diagnostic tests: urinalysis; urine culture
  • Treatment: antibiotics, antispasmodic (Pyridium)

Urinary incontinence

  • Stress Incontinence: leaking, dribbling on coughing, laughing

Effective Treatment: Kegel exercises

Imagine Elevator: contract up to 10th floor (count to 10)

Relax and lower to 1st floor (count to 10)

Repeat 10 times in a row

3-5 sets per day

  • Urge Incontinence: incontinence after strong sense of urgency; may be in small or large amounts

Effective Treatment: timed voiding (every 2 hours) and bladder retraining

gradually postpone intervals between voiding to 4-6 hrs; stabilizes bladder

Diversions

  • Urinary Stoma
  • Incontinent or continent
  • Nephrostomy
  • Tube placed in renal pelvis

Nursing Assessment

History:

  • Voiding pattern (day and night, amount)
  • Description of urine
  • Any elimination symptoms, specifically:
  • Frequency
  • Urgency (difficulty getting to bathroom)
  • Small amts or feeling of bladder fullness
  • Dysuria (painful)
  • Accidental leakage
  • Men: hesitancy (difficulty starting stream)
  • Hx of UTIs?
  • Factors influencing Urinary Elimination: meds (espec diuretics), mobility and self-toileting status, fluid intake, past illness and surgery, previous dx tests)
  • Patient Expectations

PE: Percussion for ______tenderness, palpation of bladder

Assessing Urine

  • Assessing Input/Output and 24 hr trend
  • Assessing characteristics (color, clarity, odor, hematuria)

Measuring urine

  • Measure in calibrated container from hat, bedpan or catheter bag
  • Normal = 60 ml/hr
  • * REPORT * if less than 30 ml/hr

Common Diagnostic tests:

  • To check for UTI:
  • urine dip or urinalysis (UA)
  • Urine culture

requires sterile/”Clean catch”

Identifies # and type of bacteria as well as antibiotics to which it is susceptible and resistant

  • 24 hour urine sample
  • Tests that evaluate kidney function:
  • Serum Creatinine and BUN

Interpreting Urinalysis (UA)

Infection is indicated if:

  • Presence of elevated WBC
  • Presence of nitrite
  • Presence of leukocyte esterase
  • This is a performance standard for the course

Common Nursing Diagnoses

NANDA:

  • Impaired Urinary Elimination
  • Stress Urinary Incontinence
  • Urge Urinary Incontinence
  • Total urinary incontinence
  • Urinary Retention
  • Toileting self care deficit
  • Nursing Diagnosis

As Etiology of another issue:

  • Risk for Infection R/T Urinary Incontinence
  • Risk for Impaired Skin Integrity R/T Urinary Incontinence
  • Knowledge Deficit R/T Prevention of UTI
  • Risk for Caregiver Role Strain R/T Urinary Incontinence
  • Social Isolation R/T Urinary Incontinence

Goals

Maintain or Restore Normal Voiding

Regain Normal Urine Output

Prevent Associated Risks: Infection, Skin Breakdown, Fluid/Electrolyte Imbalance, Decreased Self Esteem

Perform toileting activities independently with assistive devices

Nursing Interventions

Maintaining Normal Urinary Elimination

  • Promoting Adequate Intake (______cc/day)
  • Contraindicated if CHF, Kidney Failure
  • Maintaining Normal Voiding Habits
  • Positioning
  • Relaxation
  • Timing
  • Promotion of Complete Emptying
  • Drug Therapy

Increase emptying (in retention): Urecholine (Bethanocol)

Decrease hyperactivity of bladder (in urge incontinence) Tolterodine (Detrol), Oxybutinin (Ditropan)

Teaching: Preventing UTI:

  • Drink 8 8-oz glasses of water/day
  • Void frequently; do not “hold”
  • Void after intercourse (*evidence-based)
  • Avoid harsh soaps, bubble baths
  • Increase acidity of urine (Vit C, cranberry juice)
  • Wipe front to back

Managing Urinary Incontinence

Maintain Skin Integrity

  • Skin that is continually moist becomes macerated; urine converted to ammonia: irritating
  • After incontinence, wash thoroughly with soap and water; rinse, dry thoroughly and provide dry clothing or linen
  • Barrier creams (Zinc oxide)
  • Absorbant draw sheets
  • External Devices: condom, external catheter (not very effective)

For Stress Incontinence: ______exercises

For Urge Incontinence: Timed voiding or Bladder training

Timed voiding has been found to significantly decrease patient falls in institutions

Consider effect of socialization if living independently

Managing Foley Catheterization

40% of nosocomial infections are R/T Foleys

Nursing Interventions to Prevent UTIs in patients with Foley Catheters

  • Fluids: 3000cc/day if permitted
  • Perineal care: no special cleansing necessary but cleanse thoroughly after BM
  • Good handwashing when working with Foley and bag
  • Maintain sterile closed-drainage system
  • No need to change tubing: Do not disconnect tubing unless absolutely necessary
  • Remove catheter as soon as possible to prevent nosocomial UTI

Assessments:

  • Monitor urine output: should be at least 60cc/hr
  • If less: check placement
  • If still no improvement call MD; could be clogged or could indicate serious condition
  • Monitor color, clarity, odor of urine and mental status: at high risk for developing UTI
  • Once Foley is removed, patient should void within 6-8 hours else requires urgent assessments/interventions for urinary retention

Evaluation

Reassess voiding patterns and signs of alteration

Inspect urine

Expectations were met?

Demonstrate self care skills