Urinary Elimination

Module 34
Urinary Elimination
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Normal Structure and Function of the
Urinary System
From Patton KT, Thibodeau GA: Anatomy and physiology, ed. 8, St.
Louis, 2013, Mosby.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 2

Urinary System (Cont.)
 The urinary system is responsible for absorption
of nutrients and fluids from the body’s intake.
 It controls the composition of blood by removing
waste products known as urea and conserving
useful substances.
 Urea is produced when protein-rich foods are
digested.
 The urinary system helps to control blood
pressure and plays a crucial role in acid–base
balance.

 Kidneys
 Major excretory organs of the body
 Filter liquid waste from the blood
 Balance salts and electrolytes in the blood
 Regulate blood volume and pressure
 Produce erythropoietin for red blood cell (RBC)
formation
 Synthesize vitamin D to help with calcium levels
 Maintains acid-base balance of extracellular fluid

Urine Formation
 Urine is formed by tiny filtering units called

nephrons, which are the functional unit of the
kidney.
 Each nephron consists of the renal corpuscle and a
small tube called the renal tubule.
 The renal corpuscle is comprised of a network of
blood capillaries called the glomerulus, which is
surrounded by Bowman capsule.
 The renal tubule is comprised of the proximal tubule,
the loop of Henle, and the distal convoluted tubule.

Urine Formation (Cont.)
 Filtration initially occurs in the glomerulus as fluid
moves across a membrane as the result of a
pressure difference.
 Reabsorption occurs in the renal tubule as most of
the filtrate moves back into the blood. At this point
waste products, excess solutes, and small
amounts of water are not reabsorbed but are
secreted.
 As secretion takes place, urine is produced. Urea,
water, and other waste substances form urine as
they pass through the nephrons down the renal
tubules.
Urinary System
 Ureters
 After exiting the kidneys, urine is carried to the
bladder via narrow tubes called the ureters.
 The ureter wall muscles continually tighten and relax,
forcing urine downward.
 If urine is retained in the kidney or backflows from the
bladder toward the kidneys, the patient becomes
susceptible to kidney infections.

 Bladder and urethra
 From the ureters, the urine flows slowly into the
bladder, located below the umbilicus and above the
symphysis pubis in the lower abdomen, for storage.
 The bladder walls relax and expand to store urine,
and contract and flatten to empty urine through the
urethra.
• Sphincter muscles at the base of the bladder help keep urine
from leaking by closing tightly like a rubber band around the
opening of the bladder.
• The urethra transports urine from the bladder to outside the
body for urine elimination and bladder emptying.

Quick Quiz!
1. A patient with a long-standing history of

diabetes mellitus is voicing concerns about
kidney disease. The patient asks the nurse
where urine is formed in the kidney. The
nurse’s response is the:
A. Bladder.
B. Kidney.
C. Nephron.
D. Ureter.

Urination
 The innervation of the bladder signals when it is

time to urinate and empty the bladder. This is
referred to as urge, or urgency.
 The brain signals the bladder muscles to tighten
and the sphincter muscles to relax, which
squeezes urine out of the bladder through the
urethra.
 When all the signals occur in the correct order,
normal micturition, or urination, occurs.

Normal Urine Characteristics
 Urine can be dilute or very concentrated.

 Normal urine is sterile.
 It contains fluids, salts, and waste products, but
it is free of bacteria, viruses, and fungi.
 Urine can be produced in small or large
amounts.
 The average adult passes one to two quarts (960–
1920 mL) of urine per day, depending on the amount
of fluids consumed, medications, medical conditions,
and dietary intake (such as salt).

Altered Structure and Function
 Altered elimination:
 Urinary retention
 Loss of voluntary control of voiding
 Factors affecting the structure or function of the
urinary system
 Psychosocial factors
 Food and fluid intake
 Surgical and diagnostic procedures
 Pathologic conditions (HTN, arteriosclerosis)
 Urinary tract infections

Case Study
 Mrs. Vallero is a 65-year-old woman who has been in the
hospital for 4 days with problems related to heart failure,
fluid retention, and diabetes. She has a history of urinary
retention secondary to neuropathy caused by her
diabetes.
 Mrs. Vallero’s indwelling urinary catheter was
removed 2 days ago and subsequently was
replaced yesterday at 6 A.M. because of her inability
to urinate more than 100 mL at a time, being
incontinent of small amounts of urine, complaints of
urinary urgency, and lower abdominal pain.

Abnormal Urination Patterns
 Anuria: failure to produce or excrete 50 to 100 mL
of urine in 24 hours
 Oliguria: reduced volume: 100 to 400 mL in 24
hours
 Polyuria: excessive production and excretion of
urine
 Nocturia: excessive urination at night
 Dysuria: painful urination
 Hematuria: blood in the urine
 Urinary incontinence = the inability to control
urination
 Urinary retention: Inability to empty the bladder fully
Anuria
 Anuria, the failure of the kidneys to excrete
urine, results from any process that limits
effective blood flow through the kidneys.
 Diagnosis of anuria is made when a catheter is
passed into the bladder and no urine is present.
 Inadequate flow or complete obstruction by anything
(such as stones or tumors) that blocks both ureters
and the bladder, or obstructs the urethra, can lead to
an anuric state, resulting in acute or chronic renal
failure.
 Acute anuria is life threatening and requires emergent
investigation to determine the cause.

Anuria (Cont.)
 Dialysis is a technique by which fluids and
molecules pass through an artificial
semipermeable membrane and are filtered via
osmosis.
 During hemodialysis, the patient’s blood flows
continually from the body through vascular
catheters to the dialysis machine.
 Peritoneal dialysis is performed by instilling
dialysis solution into the patient’s abdominal
cavity through an external catheter.

Hemodialysis

Oliguria
 Oliguria is defined as reduced urine volume:
 Less then 1mL/kg/h in an infant;
 Less than 0.5 mL/kg/h in children
 Less than 400 mL/day in adults
 A symptom of acute or chronic renal failure
 Revealed by monitoring urinary output
 Classified
 Prerenal from reduced blood flow to kidneys
 Renal from actual renal damage
 Postrenal failure from obstruction of urine flow

Case Study (Cont.)
 Sandy notes that the urinary catheter was removed
at 7 A.M. this morning, and the patient has no
recorded urine output for the day. Mrs. Vallero
verifies that she has only “dribbled” urine. While
making rounds, Sandy talks with Mrs. Vallero, who
says she is worried because “I thought this was all
under control.”
 The health care provider is notified, and an order is
obtained for an intermittent catheterization. The
registered nurse on the day shift catheterizes Mrs.
Vallero at 3 P.M. with a return of 600 mL of pale,
clear yellow urine.
Safe Practice Alerts!
 Measuring and recording intake and output

(I&O) is an essential part of care for a majority of
hospitalized patients, especially those
experiencing fluid retention or excretion
problems.
 Patients with acute or chronic renal failure may
be placed on strict fluid intake restriction and
have orders for the nurse to maintain strict I&O
records.

Polyuria and Nocturia
 Polyuria is an excessive volume of urine formed
and excreted each day.
 In adults, 2500 mL or more of urine per day.
 Nocturia is excessive urination at night or
awaking several times during the night to
urinate.
 Disrupts sleep cycle
 Associated with the use of medications such as
diuretics, as well as urinary tract infections,
congestive heart failure, cystitis (inflammation of the
bladder), and diabetes.

Dysuria and Hematuria
 Dysuria = painful urination

 Many causes are possible.
 Patients complain of burning.
 Delay in initiating voiding may be associated.
 Hematuria = abnormal presence of RBCs in
urine
 Gross, visible, or microscopic hematuria may
represent serious underlying disease.
 Urine color does not reflect degree of blood loss.
 Many causes are possible.

Urinary Incontinence
 Urinary incontinence is the inability to control the
passage of urine.
 Stress incontinence is loss of urine control during
activities that increase intraabdominal pressure, such as
coughing, sneezing, laughing, or exercise.
 Urge incontinence involves a sudden strong urge to
void, followed by rapid bladder contraction.
 Mixed incontinence = stress + urge incontinence
 Functional incontinence occurs despite the fact that
the urinary tract is functioning effectively.
 Overflow incontinence is the inability to empty the
bladder completely, resulting in a constant dribbling of
urine or frequency in urination.
Urinary Retention
 Urinary retention is the inability of the bladder
to empty.
 It is caused by an obstruction in the urinary tract
or by a neurologic disorder.
 Characteristics:
 Difficulty starting a stream or emptying the bladder
 Weak urine flow
 Chronic or acute pain
• Chronic = mild but constant discomfort
• Acute = medical emergency

Factors Affecting Urinary Elimination
 Pathologic and surgical conditions

 Privacy issues and embarrassment
 Medications
 Food and fluid intake
 Ambulatory ability
 Muscle tone
 The cause of enuresis, the involuntary passing of
urine, may be structural or pathologic, although it
may be related to nonurinary problems such as
constipation, stress, and illness.

Diversity Considerations
Age: Loss of muscle tone in the bladder in older adult individuals
contributes to incontinence and frequency. Nocturia is common as
well. The bladder does not empty as efficiently in older people.
Pregnancy: The growing fetus compromises bladder space and
compresses the bladder, resulting in urinary frequency.
Gender: Enlargement of the prostate in men age 40 and older may
lead to urinary frequency, hesitancy and retention.
Urinary tract infections are more prevalent in women because women
have a shorter urethra and experience a decrease in muscle tone with
age and childbirth.
Culture: May cause patients not to seek treatment
Disability: May lead to urinary incontinence or retention
Morphology: Pressure can cause inadequate emptying and
incontinence

 Developmental factors
 Individual control of urination changes with age.
 Elderly patients are at risk for elimination problems
secondary to age-related decreased function of the
kidneys.
 Psychosocial factors
 Many people consider urination to be a private matter
and have established behaviors or habits that are
associated with voiding.
 Patients may voluntarily suppress the urge to void
secondary to other circumstances.

Quick Quiz!
2. A health care provider may suspect that a

patient is experiencing urinary retention when
the patient has:
A. Large amounts of voided cloudy urine.
B. Pain in the suprapubic region.
C. Spasms and difficulty during urination.
D. Small amounts of urine voided two to three times per
hour.

 Food and fluid intake

 Changes in a patient’s eating or drinking pattern can
disrupt normal urination.
 Medications
 Medication may alter the production, formation,
concentration, clarity, and color of urine.
 Muscle tone
 Muscle tone plays a direct role in filling and emptying
of the bladder.

Case Study (Cont.)
 As Sandy prepares to assess Mrs. Vallero again, she
remembers that urinary problems are common in
patients who have diabetes and in older adults. Age
alone does not cause incontinence. She recalls that
patients with urinary retention sometimes leak or
“dribble” urine and are then misdiagnosed as incontinent.
 She knows that patients generally void at least every 6 to
8 hours, and that Mrs. Vallero’s recent catheterization,
her decreased mobility, and her history of diabetes make
her more prone to urinary retention, incontinence of
small amounts of urine, and urinary tract infection (UTI).

(Cont.)
 Surgical and diagnostic procedures
 Surgical and diagnostic procedures alter the
formation, concentration, color, and passage of urine.
 Pathologic conditions
 Diseases of the kidneys reduce the production of
urine.
 Heart and circulatory disorders diminish blood flow to
the kidneys and affect urine production.
 Calculi may obstruct the ureter, blocking the flow of
urine.

(Cont.)
 Urinary tract infections (UTIs) are the result of
bacteria in the urine.
 UTI is the single most common hospital-acquired
infection.
 Females are more vulnerable than males, with the
rate of occurrence gradually increasing with age.
 People with an elevated risk for infection include
those with any abnormality of the urinary tract that
obstructs the flow of urine, those with catheters in
place, those who have difficulty voiding, and the
elderly with bladder control loss.

Factors Affecting Urinary Elimination (Cont.)
 A urinary
diversion is a
surgical procedure
performed when
bladder function is
impaired due to
trauma or disease
involving the
bladder, the distal
ureters, and,
From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical
rarely, the urethra. nursing: assessment and management of clinical problems, ed. 9, St.
Louis, 2014, Mosby.
 Cutaneous urinary diversion
Assessment (Cont.)
 During the initial assessment while gathering

subjective and objective data:
 Consider the patient’s physical and mental abilities
 Prioritize immediate problems identified
 Address relief of symptoms prior to full assessment.
 Note signs of distress and patient orientation
 Following a focused interview, including past and
present health history, the nurse conducts a
physical inspection of the abdomen.

Health Assessment Questions (Cont.)
Have you ever been diagnosed with kidney or bladder disease?
Have you ever had surgery or trauma to the urinary system?
Have you ever had a urinary tract or kidney infection?
Do you have a family history of kidney disease or urinary problems?
Do you have any physical problems that may affect the urinary tract,
such as high blood pressure, diabetes, kidney stones, multiple
sclerosis, Parkinson’s disease, spinal cord injury, or stroke? If so,
have you noticed or experienced any problems with urinary
retention?
Have you experienced changes in your normal urination pattern? If
so, have they caused you embarrassment or anxiety, and for how
long?
Are you able to control when you urinate?
Do you ever have to get up at night to urinate?
Do you have difficulty starting or stopping your flow of urine?

Health Assessment Questions (Cont.)
Have you noticed difficulty initiating the stream of urine? Voiding in
small amounts?
Do you feel the need to void more frequently than in the past?
Have you noticed any changes in the quality, quantity, color, or odor of
the urine? If so, for how long?
Do you take any vitamins or medications, such as antibiotics or
diuretics, or eat any particular foods that might cause changes in the
characteristics of your urine?
Do you work in an environment or industry that exposes you to harsh
chemicals?
Do you experience pain, burning, itching, or other discomfort
associated with urination or pain in the sides of your back or
abdomen? If so, describe and rate the pain on a scale of 0 to 10.
For female patients: How do you cleanse after urination or bowel
movements?

Assessment: Abdominal Examination
 Explain the
exam to the
patient.
 Inspection
 Auscultation
 Percussion and
palpation
Courtesy Verathon Corporation, Bothell, Wash.
 Bladder scan
Case Study (Cont.)
 Sandy knows that she will need to assess whether
Mrs. Vallero feels the urge to urinate. She determines
that no one has taken Mrs. Vallero to the bathroom
recently. Sandy also needs to find out more about her
patient’s urination patterns at home because Mrs. Vallero
has verbalized anxiety about her present voiding
patterns.
 Previous clinical experience has taught Sandy that
palpation of the abdomen over a distended bladder
causes some discomfort, and that the patient often
experiences an urge to urinate. Mrs. Vallero grimaces
when her abdomen is palpated and says she has a little
dolor (pain).

Assessment of Urine
 Color: Range is pale yellow to amber

 Food
 Medication
 Pathologic conditions
 Clarity: normally clear
 Odor: not very strong
 Amount: depends on fluid intake, dehydration,
retention

Urine Tests and Diagnostic
Examinations
Blood urea nitrogen and creatinine
Urinalysis: specific gravity, pH, protein,
glucose, ketones, microscopic analysis
Culture and sensitivity
24-hour urine collection
Ultrasound
Kidney, ureter, and bladder x-ray
Intravenous pyelography
Computed tomography
Cystoscopy

Laboratory Tests
 Blood urea nitrogen (BUN) and creatinine
 Blood levels of urea and creatinine are used to
evaluate renal function.
 Urea is the end product of protein metabolism and is
measured as BUN.
• BUN is a measure of the urea level in the blood.
 Creatinine is a waste product that is produced in the
blood as a byproduct of muscle metabolism.
• The patient with kidney damage has decreased urinary
creatinine but increased serum levels.
 BUN and creatinine are viewed in relationship to
each other.
Laboratory Tests (Cont.)
 Urinalysis
 Assesses urine at a single point in time
 Screens for UTI, kidney disease, other conditions
 Components
 Specific gravity: balance of water and solutes
 pH: acid–base balance
 Protein: not normally in urine
 Glucose: normal urine has little to no glucose
 Ketones: indicates fat has been broken down for
energy; not normally in the urine

 Microscopic analysis
 Urine is spun in a centrifuge and sediment settles at
the bottom. The sediment is then spread on a slide
and checked for RBCs or WBCs, casts, plugs, or
crystals.
 UTI suspicion
 Urine may be checked for nitrates. Nitrate levels
elevate when bacteria are present.
 Culture and sensitivity
 Urine in the bladder is normally sterile; it does not
contain bacteria or organisms.

 A 24-hour urine collection

 Taken to determine the amount of creatinine cleared
through the kidneys
 Also used to measure levels of protein, hormones,
minerals, and other chemical compounds in urine
 Factors affecting accuracy
• Not collecting part of the output
• Continuing beyond 24 hours
• Spilling the specimen
• Inability to keep the specimen cool
• Ingestion of certain foods or medications.

Diagnostic Examinations
 Ultrasound of the bladder or kidneys

 Assess the size, shape, and location of the kidneys
 Additional technology can monitor blood flow
 Safe for pregnant women and those with allergies to
contrast media
 Factors that interfere with results
• Severe obesity
• Recent barium studies
• Excessive flatus or intestinal gas

Diagnostic Examinations (Cont.)
 Kidney, ureter, and bladder x-ray (KUB)

 A diagnostic x-ray centered on the iliac crest used to
investigate gastrointestinal conditions such as a
bowel obstruction and gallstones
 Can detect the presence of kidney stones.
 Also used to assess positioning of indwelling devices
such as ureteric stents

 Intravenous pyelogram (IVP)
 X-ray of the kidneys, bladder, ureters, and urethra
• Images show the size, shape, and position of the urinary
tract.
• Commonly performed to identify kidney stones, tumors, or
infection; to measure the size of a tumor of the urinary tract;
and to look for urinary tract damage after injury.
 Computed tomography (CT) of the kidneys,
ureters, and bladder
• Used to diagnose kidney stones, bladder stones, or blockage
of the urinary tract
• Contrast media may be used during the procedure to look for
blockages, growths, infections, or other diseases.

 Cystoscopy = examination of the bladder and

urethra via a cystoscope inserted into the
urethra and advanced into the bladder
 Permits visualization of areas that do not show up
well on x-ray
 Performed to determine the cause of hematuria,
dysuria, incontinence, frequency, urgency, or retention
 Also used in the diagnosis of conditions that cause
blockage of the urethra
 Tissue biopsy can be performed.

Nursing Diagnosis
Impaired urinary Stress urinary Functional urinary

elimination incontinence incontinence
Urge urinary Reflex urinary Risk for impaired
incontinence incontinence skin integrity
Ineffective coping Toileting self-care Risk for infection
deficit
Pain Disturbed body Urinary retention
image

Planning
NANDA-I Nursing Nursing Nursing

Diagnosis with Outcomes Interventions
nursing diagnosis Classification Classification
statement (NOC) (NIC)
Impaired urinary Urinary Elimination Urinary Elimination
elimination related to (0503) Management
microorganisms in the Absence of urinary (0590)
urinary tract as frequency Instruct patient to
evidenced by urgency, (050331) monitor for signs
frequency and reports and symptoms of
of burning with urinary tract
urination. infection.

Planning (Cont.)
COLLABORATION AND DELEGATION
• UAP often aid patients in toileting. The nurse must communicate
assessment parameters, such as measuring the amount of
urine, noting its color, and determining the frequency. The nurse
must stress to the UAP the necessity of documenting voiding
patterns.
• Nurse continence specialists may need to be consulted to teach
pelvic floor exercises.
• Physical therapists can design a plan to increase overall muscle
strength.
• The family may need to alter the home environment to
accommodate the patient’s elimination needs, depending on
physical limitations.

Implementation and Evaluation (Cont.)
 The focus of each goal is directly related to the
identified nursing diagnosis, which in turn
determines what interventions are most
appropriate for each patient.
 The nurse must focus on activities that will help
the patient with compromised urinary elimination
return to the normal state of function or to adapt to
changes in the state of function.
 Ongoing assessment and follow-up are needed to
assure quality in the care provided and to
determine need for further nursing interventions.
Patient Education and Health Literacy
 Instruct patients and families on safe transfer techniques for
individuals with limited mobility needing voiding assistance.
 Instruct patients to respond promptly to urge to avoid urinary
retention and reduce infection risk.
 Emphasize the importance of maintaining fluid intake to help flush
the urinary system.
 Instruct patients to promptly report pain or burning on urination;
changes in urine color, odor, or clarity; or changes in voiding
patterns.
 Teach patients the importance of taking medications as prescribed.
Instruct patients and families in desired or adverse side effects that
may influence the patient’s urinary elimination pattern. Stress the
importance of maintaining fluid intake or restrictions based on the
medication.

Patient Education and Health Literacy
(Cont.)
 Reinforce with female patients proper aseptic technique, including
washing front to back to maintain cleanliness.
 Remind male patients to retract foreskin, if present, to thoroughly
wash the urinary meatus.
 Be sure to stress the importance of drying the area thoroughly to
prevent skin breakdown or irritation.
 Teach proper care of indwelling catheters and the perineal area,
including emptying and cleaning the device, maintaining a closed
system, and bladder irrigation, or flushing, if necessary.
 Arrange for a wound ostomy continence nurse (WOCN) to teach
patients with a urinary diversion appropriate care for the stoma,
drainage devices, and skin.

Home Care Considerations
• Assessing the home for safety issues related to urinary
elimination is important.
• The patient must be able to easily access toilet facilities.
Adequate lighting should be ensured.
• Necessary assistive and safety equipment, such as grab bars
and raised toilet seats, should be in place in the home prior to
discharge, as needed. Bedpans and a bedside commode, if
warranted, should be in the home ahead of time.
• Supplies necessary for catheterization and catheter care, for
urinary diversions, and for incontinence care should be
purchased.
• Appropriate referrals to home health or social services should
be made prior to discharge. Services such as home health
aides for assistance with ADLs should be confirmed.
• Community resources such as the United Ostomy Association
and National Association for Continence should be identified as
a resource for patients and their families.

Safe Practice Alert!
 The home environment should be assessed for

factors that may interfere with toileting.
 Distance to the toilet, physical layout of the
toileting facilities, clutter, stairways, rugs, and
inadequate lighting may put ambulatory patients
at safety risk.

Promoting Normal Urinary Patterns in a
Health Care Facility
 In the health care facility, there are often
conflicts with a person’s normal routine.
 Proper integration of the patient’s habits into
daily care will aid in preventing elimination
issues.
 Safe Practice Alert!
 Medications such as diuretics may cause frequency
or urgency, potentially compromising patient safety
risk. Instruct patients who are on falls precautions to
ask for assistance prior to ambulation for toileting.

Bedpan and Urinal
 The urinal is used by a patient while standing,

sitting, or lying down.
Nursing Care Guideline
 Assisting a patient with a urinal

 Background
• Routine urination and complete emptying of the bladder
prevents many complications.
• Encourage routine use of the urinal for male patients who are
unable to ambulate to the bathroom.
 Documentation concerns
• Document the quantity, color, quality, and odor of the urine.
• Note the stream characteristics.
• Monitor frequency of urination.

Safe Practice Alerts!
 Urine color, clarity, and odor should be assessed

prior to disposal.
 Urine quantity must be measured before it is
discarded to ensure accurate I&O records.
 Dehydration can pose a risk for patients trying to
control incontinence problems by avoiding
adequate fluid consumption.
 Dehydration may affect the patient’s mental
status, further contributing to risk.

Bedside Commode
 A bedside commode is a chair with a toilet seat top
that has a container underneath to collect urine or
stool for the patient who is unable to get to the
bathroom.
 The container is removed for emptying and cleaning.
Use of a bedside commode is more conducive to
elimination than the bedpan.
 A patient may need to use a bedside commode if weak
or unsteady, if the patient is at risk for falling, or
becomes short of breath when ambulating.
 It should not be used for the patient who is unable to
stand, who is maintained on strict bed rest, or who is
at safety risk in an upright position.

Promoting Normal Urinary Patterns in a
Health Care Facility (Cont.)
 Privacy
 If possible, the patient should be given time and
privacy to void.
 Toileting schedule
 Determining the patient’s toileting pattern may assist
the person with urinary elimination.
 The patient should be encouraged to void at regular
intervals whether urge is felt or not.
 Fluid intake
 Increasing fluid intake will increase urine production in
the patient without renal or cardiac dysfunction.
Case Study (Cont.)
 Findings:
 Patient is able to palpate bladder, indicating bladder
distention. During palpation, patient states she has
the sensation of bladder fullness.
 Patient complains of dribbling frequently and being
unable to urinate.
 What are the specific assessment activities that
produced these findings?
 What other assessment questions should be
asked?

Monitoring Intake & Output (I&O)
 Intake includes all food and oral fluids as well as

tube feedings and intravenous fluids.
 Oral fluids are recorded in milliliters (mL) according to
the size of the container from which they are
consumed.
 Ice chips are documented as approximately one half
of their volume.
 The volume of tube feedings and intravenous
therapies (both maintenance and piggy back) are
noted on the can or bag in which they are supplied.

Monitoring Intake & Output (I&O) (Cont.)
 Output is measured
by collecting it in bed
pans, urinals, urinary
catheters, drains,
ostomy bags,
nasogastric tubes, or
collection devices
commonly referred
to as urine “hats”
placed in the front of From Birchenall JM, Streight E: Mosby ’ s textbook for home care aide,
ed. 3, St. Louis, 2013, Mosby.
a toilet or bedside
commode.
Intake and Output Calculation
POSITIVE BALANCE
Intake Output
Oral fluid = 700 mL Urine = 940 mL
IV fluid =1250 mL Vomitus = 50 mL
8-hour Intake Total = 8-hour Output Total =
1950 mL 990 mL
I&O Balance = +960
(= 1950 - 990)

Intake and Output Calculation (Cont.)
NEGATIVE BALANCE
Intake Output
Oral fluid = 100 mL Urine = 640 mL
Tube feeding = 480 mL Hemovac drainage =
400 mL
8-hour Intake Total = 580 8-hour output total =
mL 1040 mL
I&O Balance = −460
(= 580 - 1040)

Quick Quiz!
3. A young girl is having problems urinating

postoperatively. You remember that children may
have trouble voiding:
A. In bathrooms other than their own.
B. In a urinal.
C. While lying in bed.
D. In the presence of a person other than their parents.

Kegel Exercises
 Kegel exercises help keep the female pelvic

floor toned, which reduces the risk of
incontinence.
 If performed correctly and regularly, Kegel
exercises have been shown to strengthen the
pelvic floor muscles which support the uterus,
bladder, and bowel.
 Improvement is normally seen in approximately 8 to
10 weeks.

 Kegel exercise techniques

 Background
• Kegel exercises are also known as pelvic floor
exercises.
• They improve muscle tone in the pelvic floor, which
helps to prevent stress incontinence.
• Exercises can be done while sitting or standing.
• Document that patient education was provided.

Prevention of UTIs
 Prevention is key!
 Instruct patients about ways to prevent infection
or recurrence:
 Avoid wearing tight-fitting clothing.
 Drink at least eight 8-ounce glasses of water each
day
 Urinate when the urge is felt.
 Women and girls should wipe “front to back.”
 Urinate after sexual intercourse.
 Showers are preferred instead of baths.
 Good perineal hygiene is essential.

Prevention of UTIs (Cont.)
 Treatment for a UTI requires antibiotics

 Symptom relief may be quick: 1-2 days
 Kidney infections may take weeks to resolve
 Severely ill people may need hospitalization with IV
antibiotics
 ~80% of UTIs are the result of catheterization
 Avoiding the use of indwelling catheters is a primary
method for UTI prevention.

Case Study (Cont.)
 Nursing diagnosis: Urinary retention related to

weakened detrusor muscle and recent removal
of indwelling urinary catheter
 Goal: Mrs. Vallero will have normal micturition
within 1 month.
 What expected outcomes would you establish to
measure goal achievement?

Urinary Catheterization
 Urinary
catheterization is
most often
performed through
introduction of a
catheter into the
patient’s urethra.
 Straight, Foley,
triple-lumen, and
Coudé catheters are
used for urinary Modifi ed from Wein AJ: Campbell-Walsh urology, ed. 9, Philadelphia,
catheterization. 2007, Saunders.

Urinary Catheterization (Cont.)
 Most indwelling catheters (commonly referred to as

Foley catheters) have two lumens: one for filling a
balloon at the tip of the catheter to “anchor” it in
place and the other for draining urine.
 Coudé catheters are a special type of double-lumen,
indwelling catheter that are slightly stiff and bent at
the end allowing the catheter to pass more easily
through a partially constricted urethra.
 Triple-lumen catheters are used for bladder
irrigation.

Skill 41-1: Urinary Catheterization:
Insertion and Care
PURPOSE: Urinary Catheters Are Used To:
Assess bladder function Accurately monitor urinary output
Obtain urine specimens Manage urinary incontinence
Irrigate the bladder Relieve bladder distention and
discomfort
Manage urinary Instill medications into the
retention bladder
Allow for healing after surgical procedures

Insertion and Care
 Collaboration and delegation
 Inserting a straight catheter may be delegated to
UAP) without a nurse’s assistance:
• Following assessment of the patient
• Depending upon the state and institution’s policies
and procedures
• Provided the UAP has received the appropriate
specialized training

Insertion and Care
 Collaboration and delegation
 UAP should report any of the following to the nurse:
• Patient reports of pain before, during, or after the procedure;
• Sores, wounds, irritations, or lesions noted; and/or
• Difficulties encountered while performing the procedure.
 UAPs should be instructed in:
• Sterile technique,
• Appropriate procedure and timing, and
• Required documentation.

Insertion and Care
 Evidence-based practice
 To prevent catheter-associated urinary tract infections, “insert
catheters only for appropriate indications, and leave in place
only as long as needed. For operative patients who have an
indication for an indwelling catheter, remove the catheter as
soon as possible postoperatively, preferably within 24 hours,
unless there are appropriate indications for continued use.”
 Anchoring of the catheter is imperative, not only to prevent
inadvertent dislodgement, but also to prevent pressure ulcers.
 Intermittent catheterizations have been shown to have a lower
incidence of UTIs then do indwelling catheters in acute-care
facilities, even when accounting for the same time frame of
catheter necessity.

Case Study (Cont.)
 Interventions for urinary retention care include:

 Assist with toileting every 2 to 3 hours while awake.
 Instruct the patient/family to record urinary output as
appropriate.
 Have Mrs. Vallero take a warm bath if unable to
urinate.

Skill 41-2: Closed Bladder Irrigation
 Purpose: Bladder irrigation is performed to:
 Maintain patency of catheters,
 As a postoperative procedure for genitourinary
surgeries, and
 Decrease genitourinary complications (such as
infections).
 Evidence-based practice
 “Unless obstruction is anticipated (e.g., as might
occur with bleeding after prostate or bladder surgery),
bladder irrigation is not recommended. Routine
irrigation of the bladder with antimicrobials is not
recommended.”
Skill 41-2: Closed Bladder Irrigation
 Collaboration and Delegation

 Bladder irrigation may not be delegated to UAP
without a nurse’s assistance. UAP helping to care for
the patient should report any of the following to the
nurse:
• Patient complaints of pain before or after the procedure;
• Clots noted in output;
• Change in color, odor, consistency, or amount (COCA) of
output;
• Sores, wounds, irritations, or lesions noted;
• Fever or other changes in vital signs.

Case Study (Cont.)
 Sandy talks with Mrs. Vallero the next evening.
The patient’s care plan incorporates scheduled
voiding and oral fluids. She palpates
Mrs.Vallero’s bladder and then assists her to the
toilet.
 After making sure she is comfortable and leaving
the call light in place, Sandy leaves Mrs. Vallero
to void on her own. She returns to measure Mrs.
Vallero’s urinary output and evaluates for
bladder residual using an ultrasound bladder
scan.
Discontinuing an Indwelling Catheter
 Indwelling urinary catheters should only be
placed when indicated and should be removed
as soon as possible.
 Catheter use is appropriate:
 For relief of acute urinary obstruction or retention
 During some surgical procedures
 To accurately measure urine in critically ill patients
 During perineal or sacral wound healing in incontinent
patients
 When a patient is immobilized for an extended period
of time
 For patient comfort at end of life
 Discontinuing an indwelling catheter

 Background
• Indwelling catheters are a primary source of urinary
tract infections (UTIs) and should be removed as soon
as possible.
• The Centers for Disease Control and Prevention (CDC)
has issued guidelines for insertion, use, and removal to
aid in decreasing catheter-associated UTIs.
• The patient may experience burning and difficulty
voiding, as well as frequency or retention, after
removal.

Nursing Care Guideline (Cont.)
 Discontinuing an Indwelling Catheter (Cont.)

• Record urinary output.
• Document any difficulties with performing the procedure, as
well as the patient’s response to the procedure.
• Note any patient education that was done.
• Record the findings of the urinary assessment after catheter
removal, including
 The quantity of urine, and frequency of urination, and
 The color, odor, consistency, and character of the urine.
• Include any difficulty encountered by the patient with urinary
retention and/or bladder distention.

 Discontinuing an Indwelling Catheter (Cont.)

 Evidence-based practice
• Postoperative patients should have an indwelling catheter
removed within 24 hours of surgery unless there are other
appropriate reasons for the catheter to remain in place.
• Some studies have been done regarding whether or not to
clamp the catheter prior to removing it. The evidence leans
slightly in the direction that it is better to leave the catheter
unclamped so the urine is flowing freely as the catheter is
removed. Additional studies have shown that there have
been fewer cases of bacteriuria when this practice is applied.

Routine Catheter Care
 Catheters should be inserted using aseptic technique
and sterile equipment, as recommended by the CDC.
 Once the catheter is placed, the urethral meatus should
be cleansed with soap and water once or twice daily.
 Preconnected closed drainage urinary catheterization
systems should be used to reduce risk of interruption of
the system by staff or patient’s family.
 Catheters should be changed if debris or encrustation of
the catheter is noted.
 Catheter bags should be emptied when two thirds full.

Evidence-Based Practie
 Urinary catheter infection prevention

 It is imperative that catheter bags be kept below the
level of the bladder at all times to prevent reflux of
urine into the bladder, which may lead to catheter-
acquired urinary tract infection (CAUTI).

Suprapubic Catheters
 Suprapubic catheters
are inserted directly
into the bladder just
above the pubic bone.
Surgical placement of
a suprapubic catheter
may be undertaken if
urethral
catheterization is
either contraindicated
or unsuccessful.
Condom Catheters
 Condom catheter use is less likely to lead to
bacteriuria, UTI, and death, than use of
indwelling catheters in patients who retain urine.
 However, condom catheters are not without risk:
Skin necrosis, penile strangulation and
urethrocutaneous fistulas, dermatitis, skin
erosion, pain, and localized infection have been
reported.
 Male patients report that condom catheters are
more comfortable and less painful than
indwelling catheters.

 Applying a condom
catheter
 Background
• A condom
catheter (also
known as an
external catheter
or a Texas
catheter) is used
as an
incontinence
solution for the
male patient.

 Applying a condom catheter (Cont.)
• Record any difficulties encountered with placing the catheter.
• Document urine output and the quantity, color, and odor of
the urine.
• Document neurovascular monitoring of the penis.
 Evidence-based practice
• “The use of condom catheters is less likely to lead to
bacteriuria, symptomatic UTI, or death than the use of
indwelling catheters” (Saint et al, 2006)
• It is important to note that, without proper care and routine
assessment, condom catheters can cause skin breakdown
and other complications that can lead to external infections

Perineal Care
 Skin care is important in patients with urinary

elimination issues, including those with
indwelling catheters to help prevent infection.
 Frequent perineal care is necessary, although
use of harsh soaps, bubble baths, powder, or
sprays, which can irritate the urethra, leading to
inflammation and infection, should be avoided.
 The perineal area should be cleansed with soap
and water or no-rinse cleansers frequently and
dried thoroughly.
Urinary Diversion Care
 Patients should be encouraged to provide their

own urinary diversion care, as much as possible.
 Individuals who have recently undergone
diversion surgery will require a demonstration
and patient education on how best to manage
and care for their particular type of urinary
diversion.
 Participation in a support group of others with
urinary diversions may be helpful in addressing
individual concerns.
 Urinary diversion care

 Background:
• Various disease processes or disorders, such as cancers,
spinal cord injury, or renal calculi, may necessitate the
ureters to be diverted externally from the meatus of the
bladder to the abdominal wall.
• Document patient urinary I&O.
• Note stoma condition and skin appearance.
• Record color, odor, consistency, and amount of urine.

TYPES OF URINARY DIVERSIONS
The ureters are connected to the The small bowel resection is
resected small bowel. brought to the abdominal wall.
An ileal neobladder is the most A stoma is created in the
common continent urinary abdominal wall.
diversion
The patient catheterizes the Urine drains through the stoma
stoma to drain the urine, if into a collection bag/device.
necessary.
A section of intestine is used to A stoma is created in the
create a pouch to hold urine. abdominal wall.
An ileal conduit is the most common noncontinent urinary diversion.
A section of small bowel is resected.

Obtaining Urine Specimens
 The nurse is responsible for collecting urine
specimens.
 Specimens may be collected for routine urinalysis via
normal voiding into a specimen cup or into a clean
urinal or bedpan.
 For culture and sensitivity testing, urine is collected by
the clean catch, or midstream, method, using a sterile
specimen cup.
 Specimens can also be obtained by performing a
straight catheterization using sterile technique or by
removal of a specimen from the tubing of an
indwelling catheter or urinary diversion collection bag.

Case Study (Cont.)
 Ask Mrs. Vallero about her urge to void,

sensation of bladder fullness, and dribbling
episodes.
 Have Mrs. Vallero keep a log of her pattern of
elimination, including urine output volumes with
each voiding, during the 1-month period.
 Ask Mrs. Vallero if she continues to have lower
abdominal pain.

Evaluation
 Sharing evaluation findings with patients helps

them recognize goal achievement and move
closer to healthy urinary elimination patterns
regardless of previous challenges.
 Prevention of kidney disease, urinary tract
infections, and secondary complications such as
skin breakdown related to incontinence is
ongoing, whether the patient is in a health care
facility or at home.

Case Study (Cont.)
 Mrs. Vallero is concerned about regaining her

urinary function. Sandy develops the following
outcome for her: At the end of the teaching
session, Mrs. Vallero will be able to describe
approaches to promote normal urinary
elimination habits.
 What teaching strategies would you put into the
plan?
 What evaluation strategies would you use?

Urinary Elimination

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Module 34

Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

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 Urine is formed by tiny filtering units called

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1. A patient with a long-standing history of

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 The innervation of the bladder signals when it is

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 Urine can be dilute or very concentrated.

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 Measuring and recording intake and output

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 Dysuria = painful urination

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 Pathologic and surgical conditions

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2. A health care provider may suspect that a

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 Food and fluid intake

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 During the initial assessment while gathering

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Courtesy Verathon Corporation, Bothell, Wash.

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 Color: Range is pale yellow to amber

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 A 24-hour urine collection

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 Ultrasound of the bladder or kidneys

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 Kidney, ureter, and bladder x-ray (KUB)

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 Cystoscopy = examination of the bladder and

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Impaired urinary Stress urinary Functional urinary

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NANDA-I Nursing Nursing Nursing

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