Urinary EliminationUrinary Elimination

Dr.Karima ElshamyDr.Karima Elshamy

Faculty of NursingFaculty of Nursing

Mansoura UniversityMansoura UniversityEgypt Egypt

Learning Objectives:Learning Objectives:

At the end of this lecture, the At the end of this lecture, the

student will be able to:student will be able to:

Define related terms: micturation, urine, Define related terms: micturation, urine,

Ployuria, Oliguria, Anuria, Urinary Ployuria, Oliguria, Anuria, Urinary

incontinence, Retention, Retention with incontinence, Retention, Retention with

overflow, Dysuria, Enuresis, Nocturia, overflow, Dysuria, Enuresis, Nocturia,

Urgency, Residual urine. Urgency, Residual urine.

Discuss the characteristics of normal urine. Discuss the characteristics of normal urine.

Differentiate between urinary problems. Differentiate between urinary problems.

Identify abnormal findings of urineIdentify abnormal findings of urine..

Discuss the factors, which affect the Discuss the factors, which affect the

individual's urinary elimination. individual's urinary elimination.

Discuss the nursing measures for patient Discuss the nursing measures for patient

with urinary incontinence. with urinary incontinence.

Discuss the nursing measures for patient Discuss the nursing measures for patient

suffering retentionsuffering retention. .

Outlines:Outlines:

Anatomy and physiology of the urinary Anatomy and physiology of the urinary

system.system.

Characteristics of normal urine.Characteristics of normal urine.

Signs and symptoms of urinary problems. Signs and symptoms of urinary problems.

Abnormal findings of urine.Abnormal findings of urine.

Factors which affect the individual's Factors which affect the individual's

urinary elimination.urinary elimination.

Nursing measures for patient with urinary Nursing measures for patient with urinary

incontinence. incontinence.

Nursing measures to promote proper Nursing measures to promote proper

urinary elimination for patients suffering urinary elimination for patients suffering

from urinary retention.from urinary retention.

Urinary catheterization. Urinary catheterization.

Anatomy and physiology of the Anatomy and physiology of the

urinary system:urinary system:

The urinary system is composed The urinary system is composed

of 2 kidneys, 2 ureters, the of 2 kidneys, 2 ureters, the

bladder and the urethra.bladder and the urethra.

The Kidneys:The Kidneys:

The right and left kidneys, they are The right and left kidneys, they are

complex organ whose chief function complex organ whose chief function

is the elimination of waste products is the elimination of waste products

of body metabolism and the control of body metabolism and the control

of concentration of the various of concentration of the various

constituents of the body fluid, constituents of the body fluid,

including the blood.including the blood.

Blood reaches the kidneys through the renal Blood reaches the kidneys through the renal

arteries and is filtered in the glomeration of the arteries and is filtered in the glomeration of the

nephrons. nephrons.

The nephrons are the functioning unit of the The nephrons are the functioning unit of the

kidney. kidney.

It is estimated that each kidney has about one and It is estimated that each kidney has about one and

half million nephrons. half million nephrons.

The filtrate contains water, the waste products of The filtrate contains water, the waste products of

metabolism, electrolytes and glucose. This filtrate metabolism, electrolytes and glucose. This filtrate

is known as urine. is known as urine.

Kidney Functions:Kidney Functions:

Excretion of metabolic wastes (urea, uric Excretion of metabolic wastes (urea, uric

acid, creatinine and amonia). acid, creatinine and amonia).

Regulation of acid Regulation of acid --base balance of the base balance of the

blood. blood.

Regulation of the amount of extracellular Regulation of the amount of extracellular

fluid through elimination of excess fluid or fluid through elimination of excess fluid or

fluid retention. fluid retention.

Regulation of osmotic pressure of Regulation of osmotic pressure of

extracellular fluid by regulating the amount extracellular fluid by regulating the amount

of sodium chloride and water. of sodium chloride and water.

Regulation of extracellular electrolytes by Regulation of extracellular electrolytes by

either selective reabsorption of important either selective reabsorption of important

electrolytes or excretion of excess such as electrolytes or excretion of excess such as

glucose. glucose.

Regulation of blood pressure : The kidney Regulation of blood pressure : The kidney

produces an enzyme like substance called produces an enzyme like substance called

renin that can raise blood pressure. renin that can raise blood pressure.

Regulation of red blood cell production: Regulation of red blood cell production:

Under stress, the kidney produces Under stress, the kidney produces

erythropoietin, which stimulates the erythropoietin, which stimulates the

production or red blood cells in bone production or red blood cells in bone

marrow.marrow.

Control of water excretion: The reassertion Control of water excretion: The reassertion

of water in the tubules is controlled by of water in the tubules is controlled by

pituitary and hypothalamic action. pituitary and hypothalamic action.

The Ureters:The Ureters:

Are 2 tubes, each one is connected to the Are 2 tubes, each one is connected to the

pelvis of the kidney. pelvis of the kidney.

Its chief function is to convey the urine Its chief function is to convey the urine

formed in the kidney pelvis to the bladder. formed in the kidney pelvis to the bladder.

It is about 25It is about 25--30 cm long and it has a30 cm long and it has a narrow narrow

diameter.diameter.

The Bladder:The Bladder:

Is a hollow, muscular organ that serves as a Is a hollow, muscular organ that serves as a

reservoir for urine. reservoir for urine.

The bladder can retain urine until it can be The bladder can retain urine until it can be

excreted. excreted.

The average adult bladder holds from 300 The average adult bladder holds from 300 --

500 cc of urine. 500 cc of urine.

This depends upon the efficient This depends upon the efficient

muscle tone of the bladder wall muscle tone of the bladder wall

and upon the integrity of the and upon the integrity of the

nervous system enervating the nervous system enervating the

bladder and the condition of the bladder and the condition of the

internal sphincter which' controls internal sphincter which' controls

the passage of urine from the the passage of urine from the

bladder to the urethra. bladder to the urethra.

Stimulation of the bladder is Stimulation of the bladder is transmitted by the sympathetic transmitted by the sympathetic nervous system through the hypo nervous system through the hypo gastric nerves and by the gastric nerves and by the parasympathetic nervous system parasympathetic nervous system through the pelvic nerves, i.e. the through the pelvic nerves, i.e. the smooth muscle wall of the smooth muscle wall of the bladder has a double nerve bladder has a double nerve supply. supply.

The sympathetic nervous system relaxes The sympathetic nervous system relaxes

the bladder wall to permit filling and it the bladder wall to permit filling and it

also contracts the internal sphincter to also contracts the internal sphincter to

prevent urine escaping to the exterior. prevent urine escaping to the exterior.

The external sphincter is under voluntary The external sphincter is under voluntary

control so that urine can be held in until control so that urine can be held in until

the toilet is reached and the person is the toilet is reached and the person is

ready to void. ready to void.

The parasympathetic nervous system The parasympathetic nervous system

stimulates contraction of the bladder stimulates contraction of the bladder

muscle to squeeze urine out, at the muscle to squeeze urine out, at the

same time relaxing the internal same time relaxing the internal

sphincter to permit flow of urine sphincter to permit flow of urine

along the urethra. along the urethra.

The Urethra:The Urethra:

Is a short, hollow muscular tube Is a short, hollow muscular tube

approximately 3.7 cm. long in the female and approximately 3.7 cm. long in the female and

20 cm. in the male; the chief function of the 20 cm. in the male; the chief function of the

urethra is to provide a passageurethra is to provide a passage--way through way through

which urine can be voided from the bladder. which urine can be voided from the bladder.

The entire urinary tract is lined with mucous The entire urinary tract is lined with mucous

membrane.membrane.

Micturation or Voiding:Micturation or Voiding:

It is the act by which urine is It is the act by which urine is

expelled from the bladder. The acts expelled from the bladder. The acts

of initiating and stopping maturation of initiating and stopping maturation

are normally under voluntary control are normally under voluntary control

via external sphincter muscle.via external sphincter muscle.

Urine:Urine:

Is the waste product of metabolism. Is the waste product of metabolism.

It is a complex aqueous solution of It is a complex aqueous solution of

organic and inorganic substances.organic and inorganic substances.

Characteristics of Normal Characteristics of Normal

Urine:Urine:

Amount :Amount : 1200 1200 -- 1800 cc/24 h.1800 cc/24 h.

Colour :Colour : Clear, straw, amber yellow. Clear, straw, amber yellow.

Transparency :Transparency : Transparent. Transparent.

ReactionReaction:: Slightly Acidic ph 4.5 Slightly Acidic ph 4.5 -- 6. 6.

Odor:Odor: Aromatic odor. Aromatic odor.

Specific Specific gravity:gravity: 1.005 1.005 --1.0301.030

Constituents:Constituents: Urine contains Urine contains

creatinine, uric acid, urea and a few creatinine, uric acid, urea and a few

white blood cells.white blood cells.

Frequency of Voiding:Frequency of Voiding:

The frequency of voiding varies The frequency of voiding varies

with the bladder capacity, with the bladder capacity,

sensation, acceptability and sensation, acceptability and

availability of toilet facilities. availability of toilet facilities.

Voiding 5Voiding 5--10 times a day is 10 times a day is

common.common.

Signs and Symptoms of Urinary Signs and Symptoms of Urinary Problem:Problem:

1.1. Polyuria:Polyuria: voiding a large amount of urine. voiding a large amount of urine.

2.2. Oliguria:Oliguria: Voiding a scanty amount of Voiding a scanty amount of urine. (Less than 600 cc/day) urine. (Less than 600 cc/day)

3.3. Anuria:Anuria: or urinary suppression: Total or urinary suppression: Total absence or marked deficiency i.e. absence absence or marked deficiency i.e. absence of urine emerged from the kidneys. of urine emerged from the kidneys.

4.4. Urinary incontinence:Urinary incontinence: Involuntary Involuntary voiding or constant dribbling of urine.voiding or constant dribbling of urine.

Types of urinary incontinenceTypes of urinary incontinence::

A constant incontinence. A constant incontinence.

Occasional incontinence. Occasional incontinence.

Stress incontinence. Stress incontinence.

Overflow incontinenceOverflow incontinence..

5.5. Retention:Retention:

�� Retention:Retention: The urine is formed in the The urine is formed in the

kidneys, but the patient is unable to kidneys, but the patient is unable to

excrete it from his urinary bladder. excrete it from his urinary bladder.

Retention is recognized by palpating the Retention is recognized by palpating the

distended bladder above the symphysis distended bladder above the symphysis

pubis as the urine is stagnated in. it. pubis as the urine is stagnated in. it.

�� RetentionRetention with over flow: the patients with over flow: the patients

void small amounts of urine frequently void small amounts of urine frequently

but continue to have distended bladder. but continue to have distended bladder.

6.6. Dysuria:Dysuria: Difficulty in voiding or pain in Difficulty in voiding or pain in voiding. voiding.

7.7. Nocturia:Nocturia: It is the need to get up from It is the need to get up from sleep in order to void. sleep in order to void.

8.8. Enuresis:Enuresis: It is involuntary loss of urine It is involuntary loss of urine at night (bed wetting). It persist in some at night (bed wetting). It persist in some children as late as 10 years old or more. children as late as 10 years old or more.

9.9. Urgency:Urgency: Is the sensation that one must Is the sensation that one must void. void.

10.10. Residual urine:Residual urine: When a bladder When a bladder empties normally, it retains little amount empties normally, it retains little amount of urineof urine. .

Abnormal Findings of Urine:Abnormal Findings of Urine:

Hematuria:Hematuria: Presence of blood in the Presence of blood in the urine. urine.

Pyuria:Pyuria: Presence of pus in the urine. Presence of pus in the urine.

Albuminuria:Albuminuria: Presence of albumin Presence of albumin in the urine. in the urine.

Pale urine:Pale urine: Means diluted urine may be due Means diluted urine may be due to excessive fluid intake or intake of to excessive fluid intake or intake of

diuretics. diuretics.

Glycosuria:Glycosuria: Presence of sugar in the urine. Presence of sugar in the urine.

Casts:Casts: Presence of coagulated protein from Presence of coagulated protein from the kidney tubule.the kidney tubule.

Dark urine: Means urine is concentrated, Dark urine: Means urine is concentrated,

may be due to: may be due to:

�� Dehydration, or low fluid intake, Dehydration, or low fluid intake,

�� Presence of bile pigments (urobilin or Presence of bile pigments (urobilin or

bilirubin) due to disease of the liver or bilirubin) due to disease of the liver or

gall bladder. gall bladder.

�� Intake of certain drugs such as Intake of certain drugs such as

antibiotics turns the colour of urine into antibiotics turns the colour of urine into

orange or red. orange or red.

�� Intake of certain food, vegetables and Intake of certain food, vegetables and

fruits such as carrots, beetroot and fruits such as carrots, beetroot and

blackberries.blackberries.

�� Presence of bloodPresence of blood..

Factors which affect the individual's Factors which affect the individual's

urinary elimination:urinary elimination:

•• Change in the patient's environment: Such as Change in the patient's environment: Such as

improper toilet facilities, unclean toilets or improper toilet facilities, unclean toilets or

lack of privacy. The hospital routine might lack of privacy. The hospital routine might

affect patient's habits.affect patient's habits.

•• Amount of fluid intakeAmount of fluid intake:: It can either increase It can either increase

or decrease amount ofor decrease amount of urine.urine.

•• Intake of drugs:Intake of drugs: Might lead to change Might lead to change

color of urine, or can increase urinary out color of urine, or can increase urinary out put (diuretics).put (diuretics).

•• Psychological factors:Psychological factors: Such as stress, Such as stress, fear, anxiety and emotional factors.fear, anxiety and emotional factors.

•• Pathologic conditions:Pathologic conditions: Such as fever, Such as fever,

diabetes, infection of the urinary tract.diabetes, infection of the urinary tract.

•• Disease of the nervous system or injuries Disease of the nervous system or injuries which might lead to urinary incontinence.which might lead to urinary incontinence.

•• Physical activities:Physical activities: Such as immobility.Such as immobility.

•• Blood pressure:Blood pressure: Low blood pressure Low blood pressure

(Hemorrhage) lead to low production of (Hemorrhage) lead to low production of

urine. urine.

•• Obstruction:Obstruction: Will cause stasis of urine. Will cause stasis of urine.

Obstruction may be due to congenital Obstruction may be due to congenital defect, calculi, tumor, etc.defect, calculi, tumor, etc.

•• Hormonal influencesHormonal influences:: Anti diuretic Anti diuretic

hormone secreted by the posterior lobe of hormone secreted by the posterior lobe of

pituitary gland and suppresses the amount pituitary gland and suppresses the amount

of urine produced.of urine produced.

Nursing measures for patient with Nursing measures for patient with

urinary incontinence:urinary incontinence:

•• Skin care to prevent irritation and Skin care to prevent irritation and

breakdown.breakdown.

•• Cleanliness of linen and clothes.Cleanliness of linen and clothes.

•• Frequent turning of patient to prevent Frequent turning of patient to prevent

decubitus ulcerdecubitus ulcer..

•• Perineal and abdominal exercisesPerineal and abdominal exercises..

•• Strengthening the abdominal muscle by Strengthening the abdominal muscle by

using it to aid air inhalation, Tightening using it to aid air inhalation, Tightening

and relaxing the perineal muscles 10 times and relaxing the perineal muscles 10 times

(3 times daily)(3 times daily)..

•• Bladder retraining programs.Bladder retraining programs.

•• Adjusting the fluid intake schedule.Adjusting the fluid intake schedule.

•• Emotional support. Emotional support.

Measures to promote proper urinary Measures to promote proper urinary

elimination for patients Suffering elimination for patients Suffering

from urinary retention: from urinary retention:

•• Restrict fluid intake because urine is Restrict fluid intake because urine is

accumulated in the urinary bladder be accumulated in the urinary bladder be

aware of fluid intake of patient during the aware of fluid intake of patient during the

first 24 hours.first 24 hours.

•• Provide privacy to the patient by using Provide privacy to the patient by using

curtains or closed doors.curtains or closed doors.

•• Help the patient to assume a sitting Help the patient to assume a sitting

position to help him void.position to help him void.

•• Provide a bedside commode if the patient Provide a bedside commode if the patient

cannot use the bedpan or urinal.cannot use the bedpan or urinal.

•• Listening to the sound of running water, Listening to the sound of running water,

will help the patient to void.will help the patient to void.

•• Pour warm water over the perineum of the Pour warm water over the perineum of the

female patient, or help the patient to sit in a female patient, or help the patient to sit in a

warm bath tub.warm bath tub.

•• Provide a warm bedpan or urinal.Provide a warm bedpan or urinal.

•• Supply a warm hot water bottle to the Supply a warm hot water bottle to the patient or lower abdomen.patient or lower abdomen.

•• Put the patient hands in warm water.Put the patient hands in warm water.

•• Catheterization: Should be ordered by Catheterization: Should be ordered by the physician if the pervious the physician if the pervious Measures are not successful.Measures are not successful.

Urinary Catheterization:Urinary Catheterization:

Urinary catheterization consists of inserting a Urinary catheterization consists of inserting a

thin hollow tub through the urethra into the thin hollow tub through the urethra into the

bladder to remove urine from the bladder or to bladder to remove urine from the bladder or to

establish a patient urine drainage method.establish a patient urine drainage method.