CH 48

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Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder
Urinary
Elimination
48
Process of Urination
Lower urinary tract (bladder, urethra, pelvic floor)
Cardiovascular system
Nervous system
Urine Formation
Urine is formed here
Tuft of capillaries surrounded by Bowman’s capsule
Fluids and solutes move across endothelium of capillaries into the capsule
Urine Formation (cont'd)
Bowman’s capsule
Filtrate moves from here into the tubule of the nephron
Proximal convoluted tubule
Loop of Henle
Other substances secreted
Urine Formation (cont’d)
Additional water and sodium reabsorbed here under control of hormones
Formed urine then moves to:
Calyces of the renal pelvis
Ureters (valve prevents reflux)
Bladder (detrusor muscle, trigone)
Process of Micturition
Micturition = voiding = urination
Stretch receptors transmit impulses to spinal cord voiding reflex center
Internal sphincter relaxes, stimulating urge to void
Process of Micturition (cont'd)
If appropriate, conscious portion of the brain relaxes external urethral sphincter muscle
Urine is eliminated through urethra at the meatus
Pelvic floor tone aids voluntary control
Female and Male Urinary Bladder and Urethras
See box, Female and Male Urinary Bladder and Urethras
Factors Affecting Voiding
Psychosocial factors
Factors Affecting Voiding (cont’d)
Muscle tone
Pathologic conditions
Altered Urine Production
Oliguria
Altered Urinary Elimination
Enuresis
Altered Urinary Elimination (cont’d)
Urinary incontinence
Transient (acute)
Established (chronic)
Urinary retention
Neurogenic bladder
Assessing
Examination of urine
Nursing History
Physical Assessment
Palpation and percussion of bladder
Inspection of urethral meatus for swelling, discharge, inflammation
Inspect skin for color, texture, turgor, signs of irritation, edema
Assessing Urine
96% water; 4% solutes
Organic solutes include urea (chief solute), ammonia, creatinine, and uric acid
Inorganic solutes include sodium, chloride, potassium sulfate, magnesium, and phosphorus
Assessing Urine (cont’d)
Assessing Urine (cont’d)
Nursing Diagnoses
Functional Urinary Incontinence
Overflow Urinary Incontinence
Reflex Urinary Incontinence
Nursing Diagnoses (cont'd)
Stress Urinary Incontinence
Urge Urinary Incontinence
Urinary Retention
Urinary Elimination May Become Etiology
Risk for Infection
Situational Low Self-Esteem
Toileting Self-Care Deficit
Disturbed Body Image
Urinary Elimination May Become Etiology (cont'd)
Deficient Knowledge
Risk for Social Isolation
Planning
Regain normal urine output
Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem
Perform toilet activities independently with or without assistive devices
Planning (cont'd)
Contain urine with the appropriate device, catheter, ostomy appliance, or absorbent product
Implementing
Implementing (cont’d)
Practice frequent voiding (every 2 - 4 hours)
Avoid harsh soaps, bubble baths, powder or sprays in perineal area
Avoid tight-fitting clothing
Teaching to Prevent UTIs (cont’d)
(Girls and women) - always wipe perineal area from front to back following urination or defecation
Take showers rather than baths if recurrent urinary infections are a problem
Managing urinary incontinence
Pelvic muscle exercises
Maintaining skin integrity
Managing urinary retention (flaccid bladder, Crede’s maneuver)
Methods to apply vary by manufacturer; follow instructions provided
Implementing: Performing Urinary Catheterization
Catheterization and Infection
Insertion of urinary catheters is one of most common causes of hospital-acquired (nosocomial) infections
Implementing: Nursing Care for Clients with Indwelling Catheters
Encourage large amounts of fluid intake
Provide foods that create acidic urine
Give routine perineal care; prevent contamination with feces in incontinent clients
Change catheter and tubing when necessary (sediment, impaired drainage)
Maintain sterile closed-drainage system
Nursing Care for Clients with Indwelling Catheters (cont’d)
Remove catheter as soon as possible after purpose achieved
Provide bladder retraining if needed
Follow good handwashing techniques
Implementing: Ongoing Assessments of Clients with Indwelling Catheters
Ensure tubing is free of obstructions
Ensure there is no tension on catheter or tubing
Ensure gravity drainage is maintained, with no loops in tubing below entry to drainage bag
Ensure system is well sealed or closed
Ongoing Assessments of Clients with Indwelling Catheters (cont’d)
Keep drainage receptacle below level of client’s bladder
Observe flow of urine q 2 - 3 hours
Note color, odor, abnormal constituents
If sediment is present, check more often
Implementing: Removing Indwelling Catheter
Obtain receptacle for catheter; place client in supine position; remove catheter-securing device
Insert syringe into injection port and withdraw fluid from balloon
After all fluid removed, withdraw catheter and place in receptacle
Dry perineal area
Implementing: Removing Indwelling Catheter (cont’d)
Measure and record amount of urine in drainage bag
Document removal of catheter
Provide urinal, commode, or collection device
Monitor for first voiding and amount voided in first 8 hours; monitor I&O
Observe for dysfunctional voiding behaviors
Implementing: Teaching Clean Intermittent Self-Catheterization
Performed by clients with neurogenic bladder dysfunction
Clean or medical aseptic technique
Before teaching, establish
Client voiding pattern, volume voided, fluid intake, residual amounts
Implementing: Bladder Irrigations
Catheter irrigation
To maintain or restore patency of catheter
Closed method preferred; open method occasionally required but adds risk for infection
Implementing: Suprapubic Catheter Care
Care includes
Maintaining patent system
Periodic clamping preparatory to removal
Urinary Diversions
Implementing: Nursing Care for Clients with Urinary Diversions
Assess intake and output
Note any changes in urine color, odor, or clarity (mucus shreds are commonly seen in urine of clients with ileal diversion)
Frequently assess condition of stoma and surrounding skin
Consult with wound ostomy continence nurse (WOCN) as needed
Evaluating
Nurse collects data to evaluate the effectiveness of nursing activities
If desired outcomes not achieved, explore the reasons before modifying the care plan
Client perception and understanding, access to toilet, ability to manipulate clothing, Kegel exercises
Review schedule for voiding, fluid intake (including caffeine, etc.), diuretics
Lighting, mobility aids, continence aids

CH 48

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