Chapter 36

Urinary Elimination

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Urinary System
Kidneys and ureters
Bladder
Urethra

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Kidneys and Ureters

Maintain composition and volume of body fluids

Filter and excrete blood constituents not needed; retain
those that are needed
Excrete waste product (urine)
Nephrons remove the end products of metabolism
and regulate fluid balance.
Urine from the nephrons empties into the kidneys.

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Bladder

Smooth muscle sac innervated by autonomic nervous

system
Serves as a reservoir for urine
Composed of three layers of muscle tissue called detrusor
muscle
Sphincter guards opening between urinary bladder and
urethra
Urethra conveys urine from bladder to exterior of body

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Urethra

Conveys urine from the bladder to the exterior

Male urethra functions in excretory and reproductive
systems
No portion of female urethra is external to the body

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Act of Urination

Process of emptying the bladder

Detrusor muscle contracts, internal sphincter relaxes,
urine enters posterior urethra
Muscles of perineum and external sphincter relax
Muscle of abdominal wall contracts slightly
Diaphragm lowers, micturition occurs

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Factors Affecting Urination

Developmental considerations
Food and fluid intake
Psychological variables
Activity and muscle tone
Pathologic conditions
Medications

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Developmental Considerations

Children
Toilet training 2 to 3 years old, enuresis
Effects of aging
Nocturia
Increased frequency
Urine retention and stasis
Voluntary control affected by physical problems

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Diseases Associated With Renal Problems

Congenital urinary tract abnormalities

Polycystic kidney disease
Urinary tract infection
Urinary calculi
Hypertension
Diabetes mellitus
Gout
Connective tissue disorders

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Effects of Medications on Urine

Production and Elimination
Diuretics: prevent reabsorption of water and certain
electrolytes in tubules
Cholinergic medications: stimulate contraction of
detrusor muscle, producing urination
Analgesics and tranquilizers: suppress CNS, diminish
effectiveness of neural reflex

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Medications Affecting Color of Urine

Anticoagulants: red urine

Diuretics: pale yellow urine
Pyridium: orange to orange-red urine
Elavil: green or blue-green urine
Levodopa: brown or black urine

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Using the Nursing Process

Assessing data about voiding patterns, habits, past
history of problems
Physical examination of the bladder, if indicated, and
urethral meatus; assessment of skin integrity and
hydration; and examination of the urine
Correlation of these findings with results of procedures
and diagnostic tests

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Assessing a Problem With Voiding

Explore its duration, severity, and precipitating factors.

Note the patients perception of the problem.
Check the adequacy of the patients self-care behaviors.

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Physical Assessment of
Urinary Functioning
Kidneys: Palpation of the kidneys is usually performed by
an advanced health care practitioner as part of a more
detailed assessment.
Urinary bladder: Palpate and percuss the bladder or use a
bedside scanner.
Urethral orifice: 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.

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Measuring Urine Output

For continent patients, have the patient to void into a

bedpan, urinal, or specimen container in bed or
bathroom.
Clean catch or midstream may be utilized.
Incontinent patients may require alternate techniques
Straight catheterization or indwelling catheterization will
provide sterile specimens

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Urine Specimens

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

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Diagnostic Procedures

Cystoscope
Intravenous Pyelogram (IVP)
Retrograde Pyelogram
Ultrasound procedures
CAT scan
KUB (kidneys, ureters, bladder) scan
Biopsy

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Nursing Diagnoses
Urinary functioning as the problem
Incontinence
Pattern alteration
Urinary retention
Urinary functioning as the etiology
Anxiety
Caregiver role strain
Risk for infection
Impaired skin integrity

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Planned Patient Goals

Produce sufficient quantity of urine to maintain fluid,

electrolyte, and acidbase balance.
Empty bladder completely at regular intervals without
discomfort.
Provide care for urinary diversion and know when to
notify physician.
Develop plan to modify factors contributing to current or
future urinary problems.
Correct unhealthy urinary habits.

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Promoting Normal Urination

Maintaining normal voiding habits
Schedule, provide privacy, positioning
Promoting fluid intake
Encourage and increase
Strengthening muscle tone
Kegal, mid-stream interruption
Assisting with toileting

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Patients at Risk for UTIs

Sexually active women

Women who use diaphragms for contraception
Postmenopausal women
Individuals with indwelling urinary catheter
Individuals with diabetes mellitus
Older adults

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Types of Urinary Incontinence

Transient: appears suddenly and lasts 6 months or less

Mixed: urine loss with features of two or more types of
incontinence
Overflow: overdistention and overflow of bladder
Functional: caused by factors outside the urinary tract
Reflex: emptying of the bladder without sensation of
need to void
Total: continuous, unpredictable loss of urine

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Factors to Consider With

Use of Absorbent Products
Functional disability of the patient
Type and severity of incontinence
Gender
Availability of caregivers
Failure with previous treatment programs
Patient preference

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Reasons for Catheterization

Relieving urinary retention

Obtaining a sterile urine specimen
Obtaining a urine specimen when usual methods cant be
used
Emptying bladder before, during, or after surgery
Monitoring critically ill patients
Increasing comfort for terminally ill patients

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Types of Catheterization

Straight catheterization
External (Texas or condom) catheter
Indwelling (Foley) catheter
Suprapubic catheter

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Types of Urinary Diversions

Ileal conduit
A portion of the ileum is used as an ostomy
Ureterostomy
Ureters are re-routed outside the body
Urinary (continent) pouch
Ureters are redirected to a reservoir which is able to
be catheterized for drainage

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Patient Education for Urinary Diversion

Explain reason for diversion and rationale for treatment

Demonstrate effective self-care behaviors
Describe follow-up care and support resources
Report where supplies may be obtained in the community
Verbalize related fears and concerns
Demonstrate a positive body image

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