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
