Fundamental Fundamental NursingNursing

Chapter 30Chapter 30

Urinary EliminationUrinary Elimination

Inst.: Dr. Ashraf El - JediInst.: Dr. Ashraf El - Jedi

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The urinary system The urinary system ((Fig. 30-1Fig. 30-1) consists of the ) consists of the kidneys, ureters, bladder, and urethra. These kidneys, ureters, bladder, and urethra. These major components, along with some accessory major components, along with some accessory structures such as the ring-shaped muscles structures such as the ring-shaped muscles called the internal and external sphincters, called the internal and external sphincters, work together to produce work together to produce urineurine (fluid within (fluid within the bladder), collect it, and excrete it from the the bladder), collect it, and excrete it from the body.body.

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Figure 30-1 • Major structures of the urinary system.

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Urinary eliminationUrinary elimination (the process of releasing (the process of releasing excess fluid and metabolic wastes), or excess fluid and metabolic wastes), or urination, occurs when urine is excreted. urination, occurs when urine is excreted. Under normal conditions, the average person Under normal conditions, the average person eliminates approximately 1500 to 3000 mL of eliminates approximately 1500 to 3000 mL of urine each day. The consequences of impaired urine each day. The consequences of impaired urinary elimination can be life-threatening.urinary elimination can be life-threatening.

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The need to urinate becomes apparent when The need to urinate becomes apparent when the bladder distends with approximately 150 to the bladder distends with approximately 150 to 300 mL of urine300 mL of urine. . The distention with urine The distention with urine causes increased fluid pressure, stimulating causes increased fluid pressure, stimulating stretch receptors in the bladder wall and stretch receptors in the bladder wall and creating a desire to empty it of urinecreating a desire to empty it of urine..

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Patterns of urinary elimination depend on Patterns of urinary elimination depend on physiologic physiologic emotional, emotional, social factorssocial factors. . degree of neuromuscular development degree of neuromuscular development and integrity of the spinal cord; and integrity of the spinal cord; the volume of fluid intake and the volume of fluid intake and the amount of fluid losses, the amount of fluid losses, the amount and type of food consumed; the amount and type of food consumed; the person's circadian rhythm, the person's circadian rhythm, habits, habits, opportunities for urination, opportunities for urination, and anxiety. and anxiety.

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General measures to promote urination General measures to promote urination include:include:

providing privacy, providing privacy, assuming a natural position for urination assuming a natural position for urination

((sitting for women, standing for mensitting for women, standing for men)),, maintaining an adequate fluid intake, andmaintaining an adequate fluid intake, and using stimuli such as running water from a tap using stimuli such as running water from a tap

to initiate voidingto initiate voiding..

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Characteristics of UrineCharacteristics of Urine

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Urine Specimen CollectionUrine Specimen Collection

Voided SpecimensVoided Specimens A A voided specimenvoided specimen is a sample of fresh urine is a sample of fresh urine

collected in a clean container. The first voided collected in a clean container. The first voided specimen of the day is preferred because it is specimen of the day is preferred because it is most likely to contain substantial urinary most likely to contain substantial urinary components that have accumulated during the components that have accumulated during the night. night.

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CleanClean--Catch SpecimensCatch Specimens

A A clean-catch specimenclean-catch specimen is a voided sample of is a voided sample of urine considered sterile and is sometimes urine considered sterile and is sometimes called a called a mid-stream specimenmid-stream specimen because of how because of how it is collected. it is collected.

As soon as the specimen is collected, it As soon as the specimen is collected, it is labeled and taken to the laboratory. is labeled and taken to the laboratory.

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Catheter SpecimensCatheter Specimens

A urine specimen can be collected under A urine specimen can be collected under sterile conditions using a catheter, the nurse sterile conditions using a catheter, the nurse can aspirate a sample through the lumen of a can aspirate a sample through the lumen of a latex catheter or from a selflatex catheter or from a self--sealing port sealing port ((Fig. 30-2Fig. 30-2). ).

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Figure 30-2 • Location for collecting a catheter specimen.

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2424--Hour SpecimensHour Specimens

The nurse collects, labels, and delivers a The nurse collects, labels, and delivers a 24-24-hour specimenhour specimen (collection of all urine (collection of all urine produced in a full 24-hour period) to the produced in a full 24-hour period) to the laboratory for analysis. laboratory for analysis.

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Abnormal Urine Abnormal Urine CharacteristicsCharacteristics

HematuriaHematuria: : urine containing bloodurine containing blood Pyuria: urine containing pusPyuria: urine containing pus ProteinuriaProteinuria: : urine containing plasma proteinsurine containing plasma proteins Albuminuria: urine containing albumin, a Albuminuria: urine containing albumin, a

plasma proteinplasma protein Glycosuria: urine containing glucoseGlycosuria: urine containing glucose Ketonuria: urine containing ketonesKetonuria: urine containing ketones

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Abnormal Urinary Elimination Abnormal Urinary Elimination PatternsPatterns

AnuriaAnuria AnuriaAnuria means absence of urine or a volume of 100 means absence of urine or a volume of 100

mL or less in 24 hours. It indicates that the kidneys mL or less in 24 hours. It indicates that the kidneys are not forming sufficient urine.are not forming sufficient urine.

OliguriaOliguria OliguriaOliguria, urine output less than 400 mL per 24 , urine output less than 400 mL per 24

hours, indicates inadequate elimination of urine.hours, indicates inadequate elimination of urine. Residual urineResidual urine, or more than 50 mL of urine that , or more than 50 mL of urine that

remains in the bladder after voiding remains in the bladder after voiding

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PolyuriaPolyuria PolyuriaPolyuria means greater than normal urinary means greater than normal urinary

volume and may accompany minor dietary volume and may accompany minor dietary variations. For example, consuming higher than variations. For example, consuming higher than normal amounts of fluids, especially those with normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. certain medications actually can increase urination.

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Nocturia NocturiaNocturia (nighttime urination) is unusual because (nighttime urination) is unusual because

the rate of urine production is normally reduced at the rate of urine production is normally reduced at night. night.

DysuriaDysuria DysuriaDysuria is difficult or uncomfortable voiding and is difficult or uncomfortable voiding and

a common symptom of trauma to the urethra or a a common symptom of trauma to the urethra or a bladder infection. bladder infection. FrequencyFrequency (need to urinate (need to urinate often) and often) and urgencyurgency (strong feeling that urine must (strong feeling that urine must be eliminated quickly) often accompany dysuria.be eliminated quickly) often accompany dysuria.

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IncontinenceIncontinence IncontinenceIncontinence means the inability to control either means the inability to control either

urinary or bowel elimination and is abnormal after urinary or bowel elimination and is abnormal after a person is toilet-trained.a person is toilet-trained.

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Assisting Clients with Urinary Assisting Clients with Urinary EliminationElimination

CommodeCommode A A commodecommode (chair with an opening in the seat (chair with an opening in the seat

under which a receptacle is placed) is located under which a receptacle is placed) is located beside or near the bed (beside or near the bed (Fig. 30-3Fig. 30-3).).

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Figure 30-3 • A bedside commode

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UrinalUrinal A A urinalurinal is a cylindrical container for collecting is a cylindrical container for collecting

urine. It is more easily used by males. urine. It is more easily used by males.

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Using a Bedpan

A A bedpanbedpan (seatlike container for elimination) is (seatlike container for elimination) is used to collect urine or stool. used to collect urine or stool.

Figure 30-5 • Two types of bedpans: fracture pan (left) and conventional bedpan (right).

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Catheterization CatheterizationCatheterization (act of applying or inserting a (act of applying or inserting a

hollow tube), A urinary catheter is used for hollow tube), A urinary catheter is used for various reasonsvarious reasons::

Keeping incontinent clients dry Keeping incontinent clients dry ((catheterization is catheterization is a last resort that is used only when all other a last resort that is used only when all other continence measures have been exhaustedcontinence measures have been exhausted))

Relieving bladder distention when clients cannot Relieving bladder distention when clients cannot voidvoid

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Assessing fluid balance accuratelyAssessing fluid balance accurately Keeping the bladder from becoming Keeping the bladder from becoming

distended during procedures such as surgerydistended during procedures such as surgery Measuring the residual urineMeasuring the residual urine Obtaining sterile urine specimensObtaining sterile urine specimens Instilling medication within the bladderInstilling medication within the bladder

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Types of CathetersTypes of Catheters

External CathetersExternal Catheters An An external catheterexternal catheter (urine-collecting device (urine-collecting device

applied to the skin) is not inserted within the applied to the skin) is not inserted within the bladder; instead, it surrounds the urinary meatus. bladder; instead, it surrounds the urinary meatus. Examples of external catheters are a condom Examples of external catheters are a condom catheter (catheter (Fig. 30-7Fig. 30-7)) External catheters are more External catheters are more effective for male clientseffective for male clients..

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Figure 30-7 • A condom catheter is an example of an external urine collection device.

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Straight CathetersStraight Catheters A A straight catheterstraight catheter is a urine drainage tube is a urine drainage tube

inserted but not left in place. It drains urine inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen (temporarily or provides a sterile urine specimen (Fig. 30-9Fig. 30-9).).

Retention CathetersRetention Catheters A A retention catheterretention catheter, also called an indwelling , also called an indwelling

catheter, is left in place for a period of time (see catheter, is left in place for a period of time (see Fig. 30-9Fig. 30-9). The most common type is a Foley ). The most common type is a Foley catheter.catheter.

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Figure 30-9 • Types of urinary cathetersA ) Retention (Foley) catheter with balloon. (B ) Straight catheter.

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Unlike straight catheters, retention catheters Unlike straight catheters, retention catheters are secured with a balloon that is inflated once are secured with a balloon that is inflated once the distal tip is within the bladderthe distal tip is within the bladder. . Both Both straight and retention cathetersstraight and retention catheters

Available in various diameters, sized Available in various diameters, sized according to the French scale: for adults, sizes according to the French scale: for adults, sizes 14, 16, and 18 F are commonly used.14, 16, and 18 F are commonly used.

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Inserting a CatheterInserting a Catheter

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Providing Catheter CareProviding Catheter Care

““Catheters left in place for more than a few Catheters left in place for more than a few weeks become encrusted or obstructed, and weeks become encrusted or obstructed, and lead to infectionlead to infection. . In addition, bacteria that In addition, bacteria that adhere to the urinary catheter develop a adhere to the urinary catheter develop a complex biologic structure, which protects complex biologic structure, which protects them from antibiotics” them from antibiotics”

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Catheter careCatheter care (hygiene measures used to keep (hygiene measures used to keep the meatus and adjacent area of the catheter the meatus and adjacent area of the catheter clean) helps to prevent the growth and spread clean) helps to prevent the growth and spread of colonizing pathogens. of colonizing pathogens.

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Figure 30-11 • Techniques for suspending a drainage system below the bladder: (A ) wheelchair patient; (B ) ambulating patient with and without an IV pole.

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Continuous IrrigationContinuous Irrigation

A A continuous irrigationcontinuous irrigation (ongoing instillation (ongoing instillation of solution) instills irrigating solution into a of solution) instills irrigating solution into a catheter by gravity over a period of days (catheter by gravity over a period of days (Fig. 30-12Fig. 30-12). ).

Continuous irrigations keep a catheter patent Continuous irrigations keep a catheter patent after prostate or other urologic surgery in after prostate or other urologic surgery in which blood clots and tissue debris collect which blood clots and tissue debris collect within the bladder.within the bladder.

35Figure 30-12 • Bladder irrigation using a three-way catheter

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Urinary Diversions

In a In a urinary diversionurinary diversion, one or both ureters are , one or both ureters are surgically implanted elsewhere. This surgically implanted elsewhere. This procedure is done for various life-threatening procedure is done for various life-threatening conditions. The ureters may be brought to and conditions. The ureters may be brought to and through the skin of the abdomen. A through the skin of the abdomen. A urostomyurostomy (urinary diversion that discharges urine from (urinary diversion that discharges urine from an opening on the abdomen), or implanted an opening on the abdomen), or implanted within the bowel (called an within the bowel (called an ileal conduit ileal conduit ن�اة ن�اةق� ق�

ن�ال, , ن�الق� ر�ب , , ق� بم�س� ر� ل�ك , , م�س� ل�كم�س� م�س� ) (Fig. 30-14). ) (Fig. 30-14). SPCSPC

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Figure 30-14 • Examples of urinary diversions. (A ) Ileal conduit. (B ) Cutaneous ureterostomy.

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Nursing ImplicationsNursing Implications

SelfSelf--Care DeficitCare Deficit: : ToiletingToileting Impaired Urinary EliminationImpaired Urinary Elimination Risk for InfectionRisk for Infection Stress Urinary IncontinenceStress Urinary Incontinence Urge Urinary IncontinenceUrge Urinary Incontinence Reflex Urinary IncontinenceReflex Urinary Incontinence Total Urinary IncontinenceTotal Urinary Incontinence Functional Urinary IncontinenceFunctional Urinary Incontinence Situational Low Self-EsteemSituational Low Self-Esteem Risk for Impaired Skin IntegrityRisk for Impaired Skin Integrity