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.
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