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Chapter 45

Urinary Elimination
Scientific Knowledge Base:
Organs of Urinary Elimination

Kidneys Ureters
Remove waste from the Transport urine from the
blood to form urine kidneys to the bladder

Bladder Urethra
Reservoir for urine until Urine travels from the
the urge to urinate bladder and exits
develops through the urethral
Urinary System
Urinary System Organs Renal Nephron
Additional Kidney
 Production of erythropoietin is essential to
maintaining a normal red blood cell (RBC)
 Erythropoietin stimulates bone marrow to produce
RBCs and prolongs the life of mature RBCs.

 Production of renin, prostaglandin E2, and

prostacyclin affects blood pressure.
 Renin starts a chain of events that cause water
retention, thereby increasing blood volume.
 Prostaglandin E2 and prostacyclin aid vasodilation.

 Kidneys affect calcium and phosphate

Act of Urination
 Brain structures influence bladder function.
 Voiding: Bladder contraction + Urethral
sphincter and pelvic floor muscle relaxation
1. Stretching of bladder wall signals the
micturition center in the sacral spinal cord.
2. Impulses from the micturition center in the brain
respond to or ignore this urge, thus making urination
under voluntary control.
3. When a person is ready to void, the external sphincter
relaxes, the micturition reflex stimulates the detrusor
muscle to contract, and the bladder empties.
Factors Influencing
 Disease conditions
 Medications and medical procedures
 Socioeconomic factors (need for privacy)
 Psychological factors (anxiety, stress, privacy)
 Fluid balance
 Nocturia, polyuria, oliguria, anuria
 Diuresis
 Fever
Disease Conditions Affecting
 Prerenal, renal, postrenal classification
 Conditions of the lower urinary tract
 Diabetes mellitus and neuromuscular diseases such as
multiple sclerosis
 Benign prostatic hyperplasia
 Cognitive impairments (e.g., Alzheimer’s)
 Diseases that slow or hinder physical activity
 Conditions that make it difficult to reach and use toilet
 End-stage renal disease, uremic syndrome
Medical Interventions Affecting
 Surgical procedures
 Restriction of fluid intake lowers urine output.
 Stress causes fluid retention.

 Medications
 Some cause urinary retention and/or overflow
 Some cause urgency and incontinence.
 Some change the color of urine.

 Diagnostic examinations
 Restriction of fluid intake lowers urine output.
 Direct visualization causes localized trauma and edema;
patients may have difficulty voiding.
 Renal Replacement
 Two methods
 Peritoneal
 Hemodialysis

Indications for Dialysis
Renal failure that can no longer be controlled by
conservative management (Conservative
management would include dietary modifications
and the administration of medications to correct
electrolyte abnormalities.)

Worsening of uremic syndrome associated with

which would include nausea, vomiting,
neurological changes, and pericarditis)

Severe electrolyte and/or fluid abnormalities that

cannot be controlled by simpler measures (These
abnormalities would include hyperkalemia and
pulmonary edema.) by simpler measures
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 AM 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.
Case Study (cont’d)
 Sandy notes that the urinary catheter was
removed at 7 AM 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 PM with
a return of 600 mL of pale, clear yellow urine.
Case Study (cont’d)
 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
 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).
Alterations in Urinary Elimination

Urinary retention Urinary tract

An accumulation of infection
urine due to the inability Results from
of the bladder to empty catheterization or

Urinary Urinary diversion

incontinence Diversion of urine to
Involuntary leakage of external source
Types of Urinary
Urinary Diversion

Nursing Knowledge Base
& Assessment

Infection control and hygiene

Growth and development

Muscle tone

Psychosocial considerations

Cultural considerations
Urine Collection in
 Specimen collection from infants and
children is often difficult.
 Adolescents and school-aged children
usually are able to cooperate.
 Preschool children and toddlers have
difficulty voiding on request.
Physical Assessment
 Gather nursing history for the patient’s urination
pattern and symptoms, and factors affecting
 Conduct physical assessment of the patient’s body
systems potentially affected by urinary change.
 Assess characteristics of urine.
 Assess the patient’s perception of urinary
problems as it affects self-concept and sexuality.
 Gather relevant laboratory and diagnostic test
Physical Assessment
Skin and mucosal Kidneys
membranes Flank pain may occur
Assess hydration. with infection or

Bladder Urethral meatus

Distended bladder rises Observe for discharge,
above symphysis pubis. inflammation, and
Assessment of Urine
 Intake and output
 Characteristics of urine
 Color
Pale-straw to amber color
 Clarity
Transparent unless pathology is present
 Odor
Ammonia in nature

 Urine testing
Specimen collection
Urine Tests and Diagnostic


Specific gravity


Noninvasive procedures

Invasive procedures
Case Study (cont’d)
 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 pain.
Restorative Care
 Strengthening pelvic floor muscles
 Bladder retraining
 Habit training
 Self-catheterization
 Maintenance of skin integrity
 Promotion of comfort
 Evaluate whether the patient has met
outcomes and goals.
 Check how the patient reports progress made.
 Help the patient redefine goals if necessary.
 Revise nursing interventions as indicated.
Case Study (cont’d)
 Sandy talks with Mrs. Vallero the next evening.
The patient’s care plan incorporates scheduled
voiding, oral fluids, and use of Credé’s method of
manual compression during voiding. 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 instructs her to use
Credé’s method of manual compression. She
returns to measure Mrs. Vallero’s urinary output
and evaluates for bladder residual using an
ultrasound bladder scan.
Case Study (cont’d)
 Ask Mrs. Vallero about her urge to void,
sensation of bladder fullness, and dribbling
 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.
Case Study (cont’d)
 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?