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Urinary Elimination

Scientific Knowledge Base

Urinary elimination is the last step in the removal and elimination of excess water and by products of body metabolism. Adequate elimination depends on the coordinated function of _________________________, __________________, ___________________, and _________. The kidneys filter waste products of metabolism from the blood. The ­­­­­­­­­­­­______________________

________________ from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra.

Kidney

The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver.

Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance. The normal range of urine production is ______________________________. Please convert to CC/day.  Erythropoietin, produced by the kidneys, stimulates red blood cell (RBC) production and maturation in bone marrow. The kidneys play a major role in blood pressure control via the renin-angiotensin system, release of aldosterone and prostacyclin. The kidneys also affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. 

Ureters

A ureter is attached to each kidney pelvis and carries urinary wastes to the bladder. 

Bladder

The urinary bladder is a hollow, distensible, muscular organ that holds urine. The bladder has two portions, a fixed base called the trigone and a distensible body called the detrusor. The bladder expands as it fills with urine. How much urine can the bladder hold?

Urethra

Urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence. The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area. 

Act of Urination

Brain structures influence bladder function.

Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxation

Bladder wall stretching signals micturition center.

Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.

When a person is ready to void, the central nervous system sends a message to the micturition centers, the external sphincter relaxes and the bladder empties.

Factors Influencing Urination (See Box 46-1)

Growth and development­­­­­­­­­­­_____________________________­­­____________________________

Sociocultural factors_____________________________­­­____________________________

Psychological factors_____________________________­­­____________________________

Personal habits_____________________________­­­____________________________

Fluid intake_____________________________­­­____________________________

Pathological conditions_____________________________­­­____________________________

Surgical procedures_____________________________­­­____________________________

Medications_____________________________­­­____________________________

Diagnostic Examinations_____________________________­­­____________________________

Common Urinary Elimination Problems

The most common problems involve _____________________________________________ or ________________________________________. Problems can result from 

1. I_____________________________­­­____________________________

2. I_____________________________­­­____________________________

3. O_____________________________­­­____________________________

4. I_____________________________­­­____________________________

5. I_____________________________­­­____________________________

Urinary retention_____________________________­­­____________________________

Urinary tract infection_____________________________­­­____________________________

CAUTIs

Urinary incontinence_____________________________­­­____________________________

Common forms of UI are: (See Table 46-1)

1. T_____________________________­­­____________________________

2. F_____________________________­­­____________________________

3. U/O_____________________________­­­____________________________

4. S_____________________________­­­____________________________

5. U_____________________________­­­____________________________

6. R_____________________________­­­____________________________

Urinary diversion­­­­­­­­­­­­­­­­­­­______________________________________________________________

Two types: _____________________________________________________________

A ureterostomy or ileal conduit 

Nephrostomy tubes 

Nursing Knowledge Base:________________________________________________________________

Infection control and hygiene______________________________________________________

Growth and development_________________________________________________________ (Focus on older adult Box 46-2)

Psychosocial considerations________________________________________________________

Critical thinking________________________________________________________________________

Nursing Process: Assessment (Box 46-5)

Through the patient’s eyes_________________________________________________________

Self-care ability_______________________________________________________________

Cultural considerations____________________________________________________________

(Box 46.4 cultural aspects of care)

Health literacy_______________________________________________________________

Nursing history_______________________________________________________________

(Box 46.5 Nursing assessment questions)

Pattern of urination _____________________

Symptoms of urinary alterations: (table 46-2) ___________________________________

Physical assessment

Kidneys___________________________________

Bladder___________________________________

External genitalia and urethral meatus___________________________________

perineal skin___________________________________

Assessment of urine

Intake and output___________________________________

Characteristics of urine___________________________________

Color___________________________________

Clarity___________________________________

Odor___________________________________

External genitalia and urethral meatus

Perineal skin

Laboratory and Diagnostic Testing

Diagnostic Examination (Table 46.5 Common diagnostic tests of urinary Tract)

Nursing responsibilities before testing:

1. ___________________________________

2. ___________________________________

3. ___________________________________

4. ___________________________________

Responsibilities after testing include:

1. ___________________________________

2. ___________________________________

3. ___________________________________

Nursing Diagnosis: Nursing diagnoses common to patients with urinary elimination problems: 

Functional urinary incontinence 

Stress urinary incontinence

Urge urinary incontinence

Risk for infection

Toileting self-care deficit

Impaired skin integrity

Impaired urinary elimination

Urinary retention

Planning

Goals and outcomes

Set realistic and individualized goals along with relevant outcomes

Collaborate with the patient

Setting priorities___________________________________________________________

Patient’s immediate physical and safety needs

Patient expectations and readiness to perform some self-care activities

Teamwork and collaboration______________________________________________________

Implementation

Health promotion_____________________________________________________

Patient education_____________________________________________________

Promoting normal micturition_______________________________________________

• Maintaining elimination habits

• Maintaining adequate fluid intake

Promoting complete bladder emptying______________________________________________

Preventing infection____________________________________________________

Acute care

Catheterization____________________________________________________­­­­­______________

Skill 46-2, Inserting and Removing a Straight (Intermittent) or Indwelling Catheter

Types of catheters _____________________________________________________________________

Catheter sizes_____________________________________________________________________

Catheter changes_____________________________________________________________________

Catheter drainage systems____________________________________________________________________

Routine catheter care_____________________________________________________________________

Preventing catheter associated infection (Box 46-10) _____________________________________________________________________

Catheter irrigations and instillations_______________________________________________________

Removal of indwelling catheters__________________________________________________________

Alternatives to catheterization____________________________________________________________

Suprapubic catheters External catheters

Urinary diversions

Ø Incontinent diversions

Changing a pouch

Gently cleanse the skin surrounding the stoma 

Measure the stoma and cut the opening in the pouch

Remove the adhesive backing and apply the pouch 

Press firmly into place over the stoma. 

Observe the appearance of the stoma and surrounding skin. 

Continent diversions

Orthopic neobladder

Medications

Antimuscarinics: treat urgency, frequency, nocturia and urgency UI

Bethanechol: treat urinary retention

Tamsulosin and silodosin: relax smooth muscle

Finasteride and dutasteride: shrink the prostate

Antibiotics: treat urinary tract infections

Be familiar with the medications and indications for all medications your patient is taking. 

Continuing and restorative care

Lifestyle changes

Pelvic floor muscle training

Bladder retraining

Toileting schedules

Intermittent catheterization

• Skin care

Evaluation

Through the patient’s eyes

Assess the patient’s self-image, social interactions, sexuality, and emotional status

Patient outcomes

Use the expected outcomes developed during planning to determine whether interventions were effective

Evaluate for changes in the patient’s voiding pattern and/or presence of symptoms 

Evaluate patient/caregiver compliance with the plan

Safety Guidelines for Nursing Skills

Follow principles of surgical and medical asepsis as indicated

Identify patients at risk for latex allergies 

Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

Bowel Elimination

Scientific Knowledge Base_______________________________________________________________

Mouth_____________________________________________________________________

Esophagus_____________________________________________________________________

Stomach_____________________________________________________________________

Small intestine__________________________________________________________________

Large intestine__________________________________________________________________

Anus_____________________________________________________________________

Defecation_____________________________________________________________________

Nursing Knowledge Base: Factors Affecting Bowel Elimination

Age_____________________________________________________________________

Diet_____________________________________________________________________

Fluid intake_____________________________________________________________________

Physical activity_____________________________________________________________________

Psychological factors___________________________________________________________________

Personal habits_____________________________________________________________________

Position during defecation_______________________________________________________________

Pain_____________________________________________________________________

Pregnancy_____________________________________________________________________

Surgery and anesthesia_________________________________________________________________

Medications_____________________________________________________________________

Diagnostic tests_____________________________________________________________________

Common Bowel Elimination Problems_____________________________________________________

Constipation (Box 47-1) ________________________________________________________________

Impaction____________________________________________

Diarrhea_____________________________________________________________________

Incontinence_____________________________________________________________________

Flatulence_____________________________________________________________________

Hemorrhoids_____________________________________________________________________

Bowel Diversions

Temporary or permanent artificial opening in the abdominal wall. Stoma­­­­­­­­­___________________

Surgical opening in the ileum or colon. Ileostomy or colostomy

Ostomies

Sigmoid colostomy 

Transverse colostomy

Ileostomy

Loop colostomy

End colostomy

Other Approaches

Ileoanal pouch anastomosis

Continent ileostomy

Antegrade continence enema