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Chapter 31

Chapter 31. Urinary Elimination and Care. Urinary System. Kidney—2 Ureters—2 Bladder Urethra Urinary meatus. Urinary Conditions. Dysuria: painful or difficult urination Nocturia: waking at night to urinate Oliguria: urinary output less than 30 mL per hour

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Chapter 31

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  1. Chapter 31 Urinary Elimination and Care

  2. Urinary System • Kidney—2 • Ureters—2 • Bladder • Urethra • Urinary meatus

  3. Urinary Conditions • Dysuria: painful or difficult urination • Nocturia: waking at night to urinate • Oliguria: urinary output less than 30 mL per hour • Polyuria: urinary output greater than 3,000 mL per day

  4. Normal Urinary Elimination • Urine • 95% water • 5% solutes • Dissolved in the water • Waste products resulting from cellular metabolism • Accumulate in blood

  5. Urinary Waste Products • Urea: results from amino acid metabolism • Uric acid: results from breakdown of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA) • Creatinine: the waste product of muscle metabolism

  6. Normal Urinary Elimination • Kidneys filter waste products from the blood • Eliminate in urine • Waste products, excess water, excess electrolytes, hydrogen ions that need to be eliminated, toxins, and other substances resulting from illness

  7. Normal Characteristics of Urine • Color: straw colored • Clarity: clear • Amount: 1,000 to 3,000 mL/day • Odor: mild; slightly aromatic • pH: 4.6 to 8.0 • Specific gravity: 1.010 to l.025

  8. Characteristics of Urine • Color • Directly related to hydration level • Normally yellow • Darkens with decreased hydration

  9. Characteristics of Urine • Clarity • Normally clear • Cloudy (increased turbidity) • Presence of fat globules, red or white blood cells, or bacteria • Hematuria—blood present in urine—may be visible or microscopic

  10. Characteristics of Urine • Cloudy • Excessively alkaline—causing formation of crystals • Excessively acidic—causing formation of crystals • Sediment • Any substance that settles to the bottom of a liquid • Uric acid, bacteria, mucus, and phosphates

  11. Characteristics of Urine • Cloudy • Left sitting after the specimen is collected • Components in urine start to break down • If not going to be analyzed within 1 hour—should be refrigerated

  12. Characteristics of Urine • Amount • 1,000 to 3,000 ml/24 hour • Acceptable minimal amount of urinary output per hour—30 ml • Volume of urine excreted (when fluids and electrolytes are balanced) should be within approximately 300 to 500 ml of total intake

  13. Characteristics of Urine • Oliguria • Urinary output of <30ml/hr • Causes—decreased fluid intake, dehydration, illness, urinary obstruction, renal failure, hemorrhage, or severe loss of body fluids (burns)

  14. Characteristics of Urine • Polyuria • Urinary output >3,000ml/day • Causes—excessive fluid intake, consumption of alcohol (affecting kidneys ability to reabsorb water), certain medications (diuretics)—Lasix and hydrocholorthiazide (HCTZ) • Monitor lab values—Lasix (K+), on a potassium supplement

  15. Characteristics of Urine • Anuria • Absence of urine or minimal urine production • Causes—result of temporary illness (vomiting and diarrhea due to a virus), urinary tract obstruction, or symptoms of serious underlying condition (kidney failure) • Dialysis—machine filters waste and removes excess fluid from blood

  16. Characteristics of Urine • Specific gravity • Result of comparing the weight of a substance with an equal amount of water • Normal specific gravity? • High specific gravity—urine more concentrated • Low specific gravity—urine more dilute

  17. Multiple Choice Question The nurse collecting a urine specimen from a patient knows that crystals may be in the urine due to which of the following? A. White blood cells B. Red blood cells C. Bacteria D. Increased pH

  18. Assessing Urine • Physical assessment • Color and clarity • Odor? • Volume • Edema? • Hands, legs, feet, sacrum, and face • Daily weight

  19. Assessing Urine • Frequency • Note any changes • Complaints? • Burning or difficulty starting stream • Dysuria—painful or difficult urination

  20. Urinalysis • Table 31-1 • Color and appearance • pH • Specific gravity • Odor • Bacteria

  21. Urinalysis • Protein • Leukocyte esterase • Nitrites • Glucose • Ketones • White blood cells

  22. Urinalysis • White blood cell casts • Red blood cells • Red blood cells casts • Crystals

  23. Timed Urinary Collection • 24 hour urine collection • All the urine produced within the 24 hour collection time must be collected in specimen jug • If only one void is skipped—the 24 hour collection must be restarted!

  24. Guidelines for 24 Hour Urine • Ask patient to void—discard urine—note time—starting time of urine collection • Patient starts test with an empty bladder • Post signs—24 hour urine in progress—bathrom • Keep container on ice or refrigerated

  25. Guidelines for 24 Hour Urine • If patient has indwelling catheter—place catheter collection bag in a basin of ice • 24 hours after collection began—ask patient to void—add to collection container—test completed—send to lab—remove signs

  26. Clean-catch Midstream Urine • Do not touch inside of specimen container • Female—spread labia—cleanse front to back—three times—keep labia separated—begin to void in toilet—catch urine midstream—remove specimen cup—continue to void in toilet

  27. Clean-catch Midstream Urine • Male—retract foreskin if present—cleanse tip of penis from meatus outward until entire glans is cleansed—repeat three times—each time with new wipe—begin to void in toilet—catch urine midstream—remove specimen cup—continue to void in toilet • Specimen properly labeled—send to lab--document

  28. Reagent Testing • Dipsticks • Immediate results • Must be read at specified times • Compare color changes on pads to chart on the side of dipstick container • Figure 31-2, pg. 716, Box 31-1, pg. 716

  29. Straining Urine • Renal calculi (kidney stones) • Can occur anywhere in urinary tract • Retain any placed stone • Send to lab for analysis • STRAIN ALL URINE

  30. Intake and Output • Measure fluid taken in • Measure fluid coming out • Assess for balance per shift and per 24 hr • Specimen pan, urinal—marked in mls. • Bedpan or bedside commode—empty into specimen pan—measure—avoid placing toilet tissue in with urine

  31. Alterations in Urinary Function • Bladder does not empty completely • Unable to initiate urinary stream • Urine released involuntarily • Blockages

  32. Urinary Retention • Inability to empty bladder • Inability to completely empty the bladder • Acute or chronic • Normal function til reaches bladder • If not relieved—reflux to kidneys—hydronephrosis—renal damage

  33. Causes of Urinary Retention • Kidney stones • Enlarged prostate gland • Tumor • Pregnant uterus • Infection or scar tissue • Nerve disorders • Postoperative complications

  34. Residual Urine • Urine that remains in the bladder after voiding • Maximum amount of urine left in bladder after voiding 100 ml • Palpate bladder—just above symphysis pubis—distention? • Bladder scan—Figure 31-4

  35. Bladder Scan Demo • http://www.youtube.com/watch?v=1RobLmnhoVU&feature=related

  36. Nocturia • Awaken during the night to urinate • Excessive fluid intake • Rule out—congestive heart failure, uncontrolled diabetes mellitus, UTI, enlarged prostate, or kidney disease • Talk with your doctor

  37. Types of Incontinence • Stress—increased intra-abdominal pressure • Urge—overactive bladder • Overflow—obstruction • Functional—unable to reach a bathroom • Total—unaware of need to void • Neuropathic—nerve damage

  38. Stress Incontinence • Coughing, sneezing, laughing, heavy lifting….. • Vaginal births, surgery, genetics, hormones • Pelvic floor muscles become weak • increased intra-abdominal pressure

  39. Urge Incontinence • Inability to keep urine in the bladder to reach a bathroom--overactive bladder • Void more frequently • Hear water running, hands in warm water, drinking liquid • Bladder spasms

  40. Overflow Incontinence • Bladder distended--obstruction • Urine leaking past the obstruction

  41. Incontinence • Functional—inability to reach bathroom in time • Total—loss of urine with no warning • Neuropathic—nerve damage

  42. True/False Question The nurse caring for patients in a long-term care setting knows that urinary incontinence is a normal part of the aging process. A. True B. False

  43. Managing Incontinence • Stress incontinence • Kegel exercises • Box 31-2, pg. 718 • Tighten pelvic floor muscles • Hold contraction 5 to 10 seconds • Relax for 5 to 10 seconds • 40 to 60 times throughout the day

  44. Initiating Bladder Training • Ensure adequate amount of fluids • Avoid caffeinated beverages • Drink more during a.m. and less in p.m. • Offer fluids throughout the day; avoid large volume at one time • Provide regular opportunities for toileting • Mimic patients’ normal voiding patterns

  45. Not a Candidate • Good skin care • Prevent breakdown • Change brief and perform perineal care q2h • Indwelling catheters are not used for incontinence • Can lead to UIT’s, sepsis, urethral strictures, prostatitis, and potential for bladder cancer

  46. Assisting Patients With Toileting • Offer opportunity to use bathroom/bedpan before and after meals and at bedtime • Allow male patients to void standing up if not contraindicated • Use a fracture pan for patients with hip or back surgeries • Provide privacy and avoid rushing • Offer hand hygiene after toileting

  47. Type of Catheters and Uses • Straight (single lumen) • One-time drainage or sterile specimen • Indwelling (double lumen or Foley) • Urine drainage for a specified amount of time • Three-way (triple lumen or Alcock) • Transurethral resection • Condom (Texas) • Male urinary incontinence

  48. Care of the Urinary Drainage Bag • Empty every 8 hours and document amount • Do not touch drainage spout to any surface and wipe with alcohol before closing • Always empty urine in a graduate to measure it • Maintain bag below the level of the bladder • Keep tubing free of kinks and coils • Hang on bed; do not rest on floor

  49. Catheter Care • At least once a shift • Anytime catheter is contaminated by a BM • Soap and water • Cleanse perineum • From insertion site down catheter • Do not pull or tug on catheter

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