1. Promoting Urinary Elimination
Chapter 29
Promoting Urinary Elimination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 29
Lesson 29.1
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Learning Objectives Theory
Review the structure and functions of the urinary system.
Determine abnormal appearance of a urine specimen.
Describe three nursing measures to help patients urinate normally.
Clinical Practice
Assess a patient’s urinary status.
Perform a urine dipstick test accurately.
Teach a patient how to obtain a “clean-catch” (midstream) specimen.
Assist patients with toileting.
Insert an indwelling catheter using sterile technique.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Structure of the Urinary System
Kidneys
Two bean-shaped organs 6 cm wide x 12 cm long
Located at level of L1 on either side of the spine
Each kidney contains approximately 1 million nephrons
Nephrons
Inside each nephron is a glomerulus consisting of a cluster of capillaries surrounded by Bowman’s capsule and a system of tubules
Nephrons are the working units of the kidney
Ask students to convert centimeters to inches and draw the actual size of an adult kidney (2.5 cm = 1 inch).
Ask a volunteer to draw the kidneys to scale on the board.
Reinforce there are approximately 1 million nephrons in each kidney.
Ask students to landmark the anterior and posterior position of the kidneys.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Structure of the Urinary System (cont’d)
Ureters
Hollow tubes that carry urine from the kidneys to the bladder
Each ureter is 25 to 30 cm long
Bladder
Hollow muscular organ located in lower pelvis that stores urine
Urethra
Carries urine from bladder to meatus; flow controlled by urinary sphincter
Meatus—conducts urine to outside the body
Ask students to convert centimeters to inches (2.5 cm = 1 inch) and draw the actual length of an adult ureter.
Review that the bladder is a sterile area, as well as its access and its vulnerability to infection.
Location of the bladder behind the pubic bone.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. Figure 29-1: Structures of the urinary system
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7. Figure 29-2: Tract of the male urethra
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8. Function of the Urinary System
Kidneys
Filter blood through the nephrons
Metabolic waste and excess water are extracted
Regulate electrolytes by excreting excess amounts and help with acid-base balance retaining hydrogen ions and bicarbonate
Tubules secrete, excrete, or reabsorb electrolytes, water, and other substances
Efficiency of kidney function promotes the circulation through the renal arteries and renal veins.
Kidneys receive 20% to 25% of the circulating blood supply.
The nephron is composed of three parts: proximal tubule, loop of Henle, distal tubule.
Kidneys are involved with renin production that influences blood pressure.
Filtrate collected into the distal tubules becomes urine.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Function of the Urinary System (cont’d)
Kidneys manufacture approximately 1.5 L of urine in 24 hours
Urine production related to various factors
Ureters carry urine from kidneys to bladder
Bladder stores urine and signals when it is full
Bladder empties when 250 to 400 mL of urine is present (under voluntary control)
Another rule of thumb: 1 mL of urine/kg/hour
Usual urine output for adult: 30 to 70 mL per hour
Ask students to convert mL to ounces. (30 mL = 1 ounce)
If less than 30 mL, patient may be experiencing decreased tissue perfusion and/or decreased cardiac output.
Ask the students to discuss how decreased tissue perfusion may be causing decreased urinary output.
Urine is transported through the ureters by gravity and unidirectional peristaltic waves; there are no sphincters between the bladder and the ureters.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Function of the Urinary System (cont’d)
Bladder can contain 1000 to 1800 mL of urine
Average urine output is 1000 to 1500 mL per day
Urethra carries urine from bladder sphincter to the meatus
Internal sphincter relaxes with micturition (urinating reflex)
The external sphincter is under voluntary control
At least 600 mL of urine must be excreted per day to remove waste products
The bladder is a smooth muscle controlled by the parasympathetic nervous system, making this a voluntary and learned activity.
If there is spinal cord or pelvic nerve damage, voluntary bladder control may become impaired. The bladder will continue to fill but may become distended.
Ask students to discuss bladder function and bladder care for the individual disabled by a spinal cord injury or a stroke.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Factors Interfering with Urinary Elimination
Blockage of the ureters
Stones
Tumors in the abdominal cavity
Trauma to the lower abdomen
Disruption of the bladder by tumor or trauma
Enlarged prostate
Trauma to the urethra
Infection of the urinary system
Neurologic damage
Ask the students to draw the internal anatomy and illustrate how each of the above can cause a blockage of the ureters.
Ask the students to identify specific signs and symptoms of each blockage.
Ask the students to list two assessment questions for each of the above.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Changes Occurring with Aging
Decrease in the number of functioning nephrons
Decrease in filtration rate
Decreased bladder tone—nocturia
Decreased bladder emptying, increased residual
Enlargement of prostate—urethral obstruction
Incontinence is not a normal part of aging  
Ask the students to identify two healthy lifestyle interventions for each example to minimize the effect of aging on the urinary system.
Discuss the incontinence products that are advertised on commercials. Specifically comment on the individuals portrayed, their surroundings, and how the product seems to be the “ideal solution” to the problem of incontinence.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Normal Urinary Elimination
Infants void 5 to 40 times/day
Preschool children may void every 2 hours
Adults void 5 to 10 times per day
Males void 300 to 500 mL
Females void 250 mL
Average output should be approximately 30 mL/hr
Ask the class why babies void so frequently.
Ask the class how voiding patterns for preschoolers may influence the day’s activities.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Factors Affecting Normal Urination
Neurologic and muscle development
Alterations in spinal cord integrity
Fluid volume intake
Fluid loss in perspiration
Vomiting
Diarrhea
ADH secreted by the pituitary
Antidiuretic hormone (ADH) influences fluid balance in all of these situations:
ADH responds to changes in the fluid osmolality of the blood; ADH determines how much the tubules reabsorb or discharge.
If fluid intake (by mouth, IV) is decreased (or lost through vomiting or diarrhea), ADH is released to increase the absorption of water.
If fluid intake is increased, ADH is suppressed, allowing more urine formation (diuresis).
Ask the students how they monitor ADH function by assessing the patient’s I&O and hydration status.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Characteristics of Normal Urine
Color
Straw-colored or amber
Clarity
Transparent or only slightly cloudy
Odor
Faintly like ammonia
Specific gravity
Normal range is to 1.030 pH
Slightly acid, ranging from 5.5 to 7.0
Remind students to always use barrier precautions when dealing with urine.
Urine specific gravity is influenced by protein and glucose.
Urine specific gravity is also influenced by the use of IV contrast used for imaging studies.
pH: Compare with normal blood pH (7.35–7.45).
pH: Indication of the kidney’s compensatory mechanism for acid-base balance of the blood.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Alterations in Urinary Elimination Patterns
Anuria
Less than 100 mL of urine output in 24 hours
Dysuria
Painful or difficult urination; may be from infection or trauma
Incontinence
Involuntary release of urine
Ask the students if they have cared for patients with these symptoms. Review documentation.
Several types of renal function tests are available to determine the cause of these symptoms; renal function tests are ordered by the physician to evaluate the cause and severity of changes in renal function.
Many renal function test results will remain within normal limits until renal function decreases 50% or more.
Often patient symptoms may indicate an ongoing problem that has been compensated for until the symptoms became apparent.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Alterations in Urinary Elimination Patterns (cont’d)
Nocturia
When a person has to get up more than twice in the night to void
Oliguria
Decreased urine output less than 400 mL in 24 hours
Polyuria
Excessive urination (>1500 mL in 24 hours)
Common renal function tests include renal concentration, creatinine clearance, serum creatinine, and BUN
Ask the students about the nurse’s role for patient care undergoing these tests:
Ongoing patient assessment
Documentation of symptoms
Reporting changes in I&O, not just at the end of the shift but throughout the shift as needed
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Alterations in Urinary Elimination Patterns (cont’d)
Cystitis
Inflammation of the bladder
May be caused by irritation of highly concentrated urine, pathogenic bacteria, injury, or instillation of an irritating substance
Symptoms: frequency, urgency, dysuria, burning, malaise, foul-smelling urine, slight temperature elevation
What bacteria are often responsible for cystitis?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Urinary Specimens Normal voided specimen
Send to the laboratory within 5 to 10 minutes
Urine standing more than 15 minutes changes characteristics
Midstream (clean-catch) specimen
Specimen from an indwelling catheter
Sterile catheterized specimen
24-hour specimen
Strained specimen
Ask the students to identify the rationale for obtaining each of these specimens.
Review the nurse’s role for obtaining urine specimens:
Patient teaching
Barrier precautions
Sterile technique
Timely collection
Prompt transport to lab
Monitoring and reporting results
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Figure 29-3: Urine collection devices
Discuss urine collection devices and how they can support patient comfort and assist with urination.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Abnormalities Found in Urine
Glycosuria
Glucose in the urine
Proteinuria
Protein in the urine
Hematuria
Blood in the urine
Pyuria
Pus in the urine
Ketonuria
Ketones in the urine
Ask the students if they have cared for a patient with these types of symptoms or urinalysis report results; discuss the significance of each.
Based on these results, imaging diagnostic studies may be ordered:
Ultrasound
KUB x-ray
CAT and MRI for sectional images
IVP; cystogram
Renal angiography; pyelography
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Assessment Patients should be assessed for:
Usual pattern of elimination
Incidences of incontinence, frequent urination
Burning on urination
Sense of urgency
Times of day for elimination
Total daily fluid intake
Discuss with the students why documentation of each of these would be important assessment information.
Assessment findings may determine the need for further diagnostic tests, specifically diagnostic endoscopy:
Cystoscopy
Renal biopsy
Renal endoscopy
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Question 1
The urinary system is made up of which of the following structures?
Ureters, bladder, kidneys, urethra
Ureters, bladder, kidneys, prostate
Bladder, kidneys, urethra, urostomy
Urinometer, bladder, kidneys, urinary meatus
Answer: 1
Rationale: The urinary system is made up of kidneys, ureters, bladder, and urethra in the male and female. The prostate is only present in males and is not considered part of the urinary system. A urostomy is an opening where the ureter exits the abdominal wall to discharge urine. A urinometer is an instrument to measure urine.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Question 2
Erin’s patient has been complaining of burning when she urinates. Her doctor ordered a urinalysis, which shows pyuria. These results indicate:
there is an increased amount of protein.
liver disease or an obstruction of the bile duct.
there is blood in the urine.
there is pus in the urine.
Answer: 4
Rationale: Pyuria is pus in the urine, which usually means bacteria are present in the bladder or kidneys. Proteinuria is protein in the urine. Bilirubin in the urine suggests liver disease or an obstruction of the bile duct. Hematuria is blood in the urine.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Chapter 29
Lesson 29.2
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26. Learning Objectives Theory
Compare and contrast the purposes and principles of indwelling and intermittent catheterization.
Summarize the rationale for using a continuous bladder irrigation system.
Analyze different methods of managing urinary incontinence.
Clinical Practice
Insert an indwelling catheter using sterile technique. (Continued)
Perform catheter care.
Teach a patient how to perform Kegel exercises.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Types of Urinary Catheters/Specimens
Catheter types
Robinson
Foley
Suprapubic
Coudé
Alcock
de Pezzer
Malecot
Condom
Specimen types
Routine
Midstream
Indwelling catheter
Sterile
24-hour
Strained
Inserting a catheter (see Skill 29-2)
Ask the students to simply illustrate each different catheter type; discuss the rationale for the different catheter types. (If possible, secure some of the different types listed and pass them around the class.)
Ask the students to identify the nurse’s role in caring for the patient with a catheter.
Ask the students to identify the essentials of documentation for the patient with a catheter.
Ask the students to identify abnormal assessment findings and how they should be documented/reported.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

28. Figure 29-8: Common urinary catheters
Discuss the single lumen urinary catheter and its uses.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

29. Figure 29-8: Common urinary catheters (cont’d)
Discuss the double lumen urinary catheter and its uses.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Figure 29-8: Common urinary catheters (cont’d)
Discuss the triple lumen Alcock urinary catheter and its uses.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

31. Figure 29-9: Side-lying position for catheterization
Discuss when to use side-lying position for catheterization.
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32. Figure 29-10: Suprapubic catheter
Discuss the urinary catheter and its uses.
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33. Incontinence Loss of normal bladder control
Body image disturbance, Increased risk for impaired skin integrity, Increased risk for infection
May be temporary or permanent
May be corrected by surgery
May be helped by performing Kegel exercises
Voiding studies measure the various pressures in the bladder, meatus, urethra, and ureter and include:
Uroflowmetry; cystometrogram; urethral pressure profile
Cystourethrogram; voiding cystogram
Discuss the importance of Kegel exercises.
Electromyography—evaluate the neuromuscular function of urination.
Discuss the nurse’s role in patient preparation and teaching for diagnostic testing.
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34. Urinary Diversion Necessary when the bladder is removed or bypassed
One or both ureters are implanted into:
The abdominal wall (urostomy)
The bowel
A pouch constructed from a piece of bowel
Skin care depends on the type of diversion
Diversion is usually a result of surgery.
May be temporary or permanent.
Discuss the rationale for urinary diversion.
Ask students to share their experience in caring for a patient with a urinary diversion
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35. Documentation of Voiding
When a patient is voiding normally (voiding sufficiently )
Whether there is a problem voiding (i.e., dysuria)
Whether the patient is continent
The amount of urine output
Any bladder irrigations
Presence of an indwelling catheter (or when it is removed)
Ask the students to summarize the importance of documentation, when it is okay to document, and when it is important to notify the charge nurse or physician directly.
Review the importance of:
Ongoing patient assessment of symptoms
I&O
Patient hydration status
Some patients are reluctant to discuss urinary elimination based on age, cultural practice, privacy, and personal preference.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

36. Question 3
Brenda is making rounds on her postoperative patient. She notices her patient’s Foley has drained 90 mL in 3 hours. Which statement is correct?
This is a severe decrease in urine output.
This is an average amount of urine output.
This is a slightly above-average amount of urine output.
This is an excessive amount of urine for a postoperative patient.
Answer: 2
Rationale: There should be an average hourly amount of 30 mL urinary output. In 3 hours, 90 mL would be average for an adult.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

37. Question 4
Erin’s patient will be going home with a catheter. All of the following are true regarding a Foley catheter except:
it is the most common type of indwelling catheter.
it has two lumens.
the balloon is inflated to 15 mL.
it may also be used for suprapubic drainage
Answer: 3
Rationale: The balloon is inflated 5 to 10 mL. It is the most common indwelling catheter; it has two lumens and may be used as suprapubic drainage.
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38. Question 5
Bruce’s patient needs a condom catheter. This type of catheter is used when:
the patient cannot void.
a man or woman has bladder surgery.
a female is incontinent.
a male is incontinent.
Answer: 4
Rationale: A condom catheter is used only for males who are incontinent but can void on their own. An indwelling catheter is used for a patient who cannot void or for a man or woman following surgery. The female incontinent patient cannot wear a condom.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.