URINARY URINARY ELIMINATIONELIMINATIONMa. Tosca Cybil A. Torres, RN, MAN

PRETEST: IDENTIFY THE PARTS OF THE URINARY SYSTEM

Pretest:

• The urinary system consists of organs that produce and excrete urine from the body.

• Urine contains waste: mostly excess water, salts and nitrogen compounds.

• Primary organs are the kidneys• Normal adult bladder can store

up to .5 liters.• Also responsible for regulating

blood volume and blood pressure.

• Regulates electrolytes.

Organs of the Urinary System

The components of the urinary system include :

• the kidneys• the ureters• the urinary

bladder • the urethra.

KidneysThe kidneys are bean-shaped organs

located at the back of the abdominal cavity.

They lie on either side of the spinal column.

This area is known as the flank area and is against the muscles of the back.

The external kidney has a notch at the concave border known as the hilum.

The hilum is the entrance for renal artery, veins, nerves and lymphatic vessels.

Internal Structure of the Kidney

• The cortex is the outer layer; arteries, veins, convoluted tubes and glomerular capsules

• The medulla is the inner layer; renal pyramids

Nephrons

• 1 million nephrons• The functional unit of the kidney• Remove waste products of metabolism

from the blood plasma.• Waste products are urea, uric acid,

creatinine, sodium, potassium chloride and ketone bodies.

Urine formation:

Ureters, bladder and urethra

• Ureters -tubes that carry newly formed urine from the bladder to the kidneys.

• Bladder-muscular sac that serves as a reservoir for urine; bladder stretches to accommodate urine.

• Urethra- tube extends from the bladder to the external opening of the urinary system, the urinary meatus

Urine

• The formation of urine has 3 processes, filtration, reabsorption and tubular secretion.

• Urine consists of 95% water and 5% solid substances.

• The need to urinate is usually felt at 300-350ml of urine in the bladder.

• Typically 1000-1500 mL is voided daily.

Physical Characteristics of Urine

• Odor– Fresh urine is slightly

aromatic

– Standing urine develops an ammonia odor

– Some drugs and vegetables (asparagus) alter the usual odor

Physical Characteristics of Urine

• pH – Slightly acidic (pH 6) with a range of 4.5

to 8.0– Diet can alter pH

• Specific gravity– Ranges from 1.010 to 1.025 – Dependent on solute concentration

Chemical Characteristics of Urine

• Urine is 95% water and 5% solutes

• Nitrogenous wastes (organic solutes) include urea, ammonia, uric acid, and creatinine

• Other normal solutes include:

– Sodium, potassium, phosphate, and sulfate ions

– Calcium, magnesium, and bicarbonate ions

• NaCl is the most abundant inorganic salt in the urine.

• Urea is the chief organic solute.

• Abnormally high concentrations of any urinary constituents may indicate pathology

• Disease states alter urine composition dramatically

Lifespan considerations

Child• At 10 weeks

gestation the kidney begin to form

• Newborns kidneys are not able to concentrate urine

• Kidneys are more susceptible to trauma

• Diapers- more susceptible to UTI

Older Adult• Kidney lose mass and the

blood vessels degenerate• Kidneys lose their ability to

filter• Dehydration can happen

more quickly• Electrolyte balance

happens more quickly• Loss of muscles tome in

urinary structures• Decreased bladder

capacity

Urination

• Micturation, voiding, and urination all refer to the process of emptying the urinary bladder

• Stretch receptors- special sensory nerve endings in the bladder wall that is stimulated when pressure is felt from the collection of urine – Adult: 250-450mL of urine– Children: 50-200mL of urine

Factors affecting voiding

• Growth and development• Psychosocial factors • Fluid and food intake • Medications • Muscle tone and activity • Pathologic conditions • Surgical and diagnostic

procedures

Altered Urine Production

• Polyuria- a.k.a. diuresis– production of abnormally large amounts of urine

by the kidneys – 2500mL/day for adults – Causes:

• Excessive fluid intake • Intake of alcohol and caffeine • Diabetes mellitus • Hormone imbalances • CKD

– Other signs associated with diuresis: polydipsia, dehydration and weight loss

Oliguria • Voiding scant amounts of urine • Less than 500mL/day

Anuria• Voiding less than 100mL/day

• May result from low fluid intake, kidney disease, severe heart failure, burns and shock

• Usually accompanied by fever and heavy respiration

Altered urinary Elimination

Frequency- voiding at frequent intervals that is more often than usual.

• Total amount of urine voided may be normal but amount of each voiding are small---50-100mL

• May result from increased fluid intake, cystitis, stress, or pressure on the bladder

Nocturia or nycturia- increased frequency at night that is not a result of an increased fluid intake

• Expressed in terms number of times the person gets out of bed to void

Altered urinary Elimination

Urgency- feeling that the person must void. • Usually accompanies psychologic stress, and

irritation of the urethra• Common in young children who have poor

external sphincter control

Dysuria- voiding that is either painful or difficult • May result from stricture of the urethra, urinary

infections, injury to the bladder and/ or the urethra.

• Described as a burning sensation during voiding • Burning during micturation if often due to an

irritated urethra. Burning following urination may be a result of bladder infection

• Often associated with urinary hesitancy (delay and difficulty in initiating voiding)

Altered urinary Elimination

Enuresis- repeated involuntary urination in children beyond the age when voluntary bladder control in normally acquired (4-5yrs)

Urinary incontinence- is considered a symptom, not a disease.

Types:

• Functional incontinence- involuntary unpredictable passage of urine

• Reflex incontinence- involuntary loss of urine occurring at somewhat predictable intervals when a specific bladder volume is reached.

• Stress incontinence- loss of urine of less than 50cc occurring with increased intra-abdominal pressure

• Total incontinence- continuous and unpredictable loss of urine.

• Urge incontinence- involuntary passage of urine occuring soon after a strong sense of urgency to void.

*urinary retention with overflow- dribbling incontinence that results when the bladder is greatly distended with urine because of an obstruction

Neurogenic bladder- describes any voiding problem related to neurologic impairment or dysfunction.

Altered urinary Elimination

Altered urinary Elimination

Urinary retention- accumulation of urine in the bladder (as much as 3L) with associated inability of the bladder to empty itself.

Adult- can hold 250-450ml of urine in the bladder before micturation reflex in triggered.

• Prolonged retention leads to stasis (slowing of the flow of urine) and stagnation of urine which increases the possibility of UTI.

• Retention if distinguished from oliguria or anuria by the distention of the bladder.

• Characterized by small, frequent voiding or absence of urine output

Assessment

Nursing history

a.Data about voiding patterns and habits, any problems voiding, and past or present problems involving the urinary system

b.Data about any problems that may affect urination

Collecting urine specimens

• Clean catch or midstream specimens must be free as possible from external contamination by MO near the urethral opening.

• About 120ml of urine is generally required for examination.

General guidelines: • The specimen must be free of fecal contamination • Female clients should discard toilet tissue in the

toilet or trash bins rather than in the bedpan• Put lid tightly on the container to prevent spillage of

the urine and contamination of other objects• If the outside of the container has been

contaminated, clean it with a disinfectant.

Collecting a Timed Urine Specimen

• May short periods (1-2hrs) or long periods (12-24hrs)

Steps:

Place alert signs about the specimen collection at the client’s bedside or bathroom

Label specimen containers to include date and time of each voiding as well as the usual client ID data. Containers may be numbered sequentially

Explain to the client the purpose of the test, when it begins, or what to do with it.

Measuring Residual Urine

residual urine- urine remaining in the bladder following the voiding

Purposes of measuring residual urine: • To determine the degree to which the bladder

is emptying • Assess the need to establish therapy that will

empty the bladder.

* To measure the residual urine, the nurse asks the client to void then immediately catheterizes the client.

Diagnostic tests

• Urinalysis • Blood tests: (BUN and Creatinine

clearance) • Cystoscopy • Intravenous pyelogram (IVP)/ excretory

pyelogram • Retrograde pyelogram • CAT scan • UTZ

Diagnosing: Possible nursing diagnoses: • Incontinence

– Functional incontinence– Reflex incontinence– Stress incontinence– Total incontinence– Urge incontinence

• Altered urinary elimination • Urinary retention• High risk for infection • Self-esteem disturbance• High risk for impaired skin integrity • Social isolation • Self care deficit: toileting

Implementing Maintaining Normal Urinary Elimination

• Promoting normal fluid intake

• Maintaining normal voiding habits – Relaxation

• Provide privacy • Allow client sufficient time to void • Suggest the client to read or listen to music • Provide sensory stimuli • Pour warm water over perineum or have the client sit in a warm bath to promote

muscle relaxation• Apply hot-water bottle to the lower abdomen • Turn on running water within hearing distance • Relieve physical or emotional discomfort

– Timing • Assist clients to have the urge to void immediately• Offer toileting assistance at usual times of voiding

– Positioning • Assist client in a normal position for voiding • Use bedside commodes as necessary for females and urinals for males standing

at bedside• Encourage client to push over the pubic area with hands or to lean forward

Managing Urinary Incontinence (UI)

• Continence (bladder) training

• Bladder training- requires that the client postpone voiding, resist or inhibit the sensation urgency, and void according to a timetable rather than according to the urge to void. The goal is to lengthen the intervals between urination to correct the client’s habit of frequent urination

• Habit training- also referred to as timed voiding or scheduled toileting. There is no attempt to motivate the client to delay voiding is the urge occurs.

• Prompt voiding- supplements the habit training by encouraging the client to use the toilet and reminding the client when to void

Pelvic Muscle Exercises (PME)

• Referred to as perineal muscle tightening or Kegel’s exercises

• Streghthen pubococcygeal muscles and can increase the incontinent female’s ability to start and stop the stream of urine

Managing Urinary Incontinence (UI)

Managing Urinary Incontinence (UI)

• Positive reinforcements• Maintaining skin integrity • Applying external urinary devices

Managing Urinary Retention

• Urinary catheterization