chapter 46 urinary elimination a basic human function is urinary elimination and this can be compromised by illnesses or various conditions as nurses we are key when treating patients with urinary problems urinary elimination is the last step in removal and the elimination of excess water and byproducts of body metabolism adequate elimination depends on coordinated functions of kidneys ureters bladder and urethra the kidneys lie retroperitoneal on either side of the vertebral column behind the peritoneum and against the deep muscles of the back normally the left kidney is higher than the right kidney because of the anatomical position of the liver the nephrons or the functional unit of the kidneys remove the waste products from the blood and play a major role in regulation of fluid and electrolyte balance the ureter is attached to each kidney pelvis and it carries urinary waste to the bladder the urine draining from the ureters to the bladder is sterile peristaltic waves cause the urine to enter the bladder in spurts rather than steadily the bladder is a hollow distendable muscular organ that holds urine when empty the bladder lies in the pelvic cavity behind the symphysis pubis the urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus the urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles 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 bladder kidney nephron ureter the answer is c nephron sandy the nursing student learns about the patient at the 3 pm shift report what questions would you have if you were the nursing student what do you believe is happening with the patient types of urinary diversions in image a this is a consonant urinary reservoir and in image b it is a urostomy or an ileoconduit urination mic duration and voiding are all terms that describe the process of emptying the bladder micturation is a complex interaction among the bladder urinary sphincter and central nervous system most common urinary elimination problems involve the inability to store urine or fully empty urine from the bladder urinary retention is the inability to partially or completely empty the bladder acute or rapid onset urinary retention stretches the bladder causing feelings of pressure discomfort maybe pain or tenderness over the symphysis puber pubis and causes restless and ness in the patient and sometimes diaphoresis urinary tract infections are the fourth common type of healthcare associated infection and these are virtually all caused by instrumentation in the urinary tract what should this nurse do at the next assessment urinary incontinence is defined as the complaint of any involuntary loss of urine and it is a common problem 27 of men and 43 percent of women over the age of 40 as well as 20 to 40 percent of older adults and 70 percent of elderly nursing home patients have urinary incontinence common forms of urinary incontinence are urge or urgency this is an involuntary leakage associated with urgency and stress urinary incontinence which is an involuntary loss of urine associated with effort or exertion on sneezing or coughing patients who had bladder removal surgery or a cystectomy because of cancer or significant bladder dysfunction related to radiation injury or neurogenic dysfunction with frequent urinary tract infections may require a surgical procedure that diverts the urine to the outside of the body through an opening in the abdominal wall called a stoma urinary diversions are constructed from a section of intestine to create a storage reservoir or a conduit for urine diversions may be temporary or permanent continent or incontinent a healthcare provider may suspect that a patient is experiencing urinary retention when the patient has large amounts of voided cloudy urine pain in the super pre-suprapubic region spasms and difficulty during urination small amounts of urine voided two to three times per hour the answer is d small amounts of urine voided two to three times per hour because of heart failure and bed rest have left the patient in a weakened state sandy the nursing student is flexible and creative in designing a plan of care to meet the patient's elimination needs what additional assessments should be performed routinely the urinary tract is considered sterile the use of infection control principles is necessary to help prevent the development and the spread of urinary tract infections it is important to apply knowledge of normal growth and development when caring for the patient with urinary problems a patient's ability to control mic duration changes during the lifespan self-concept culture and sexuality are all closely related concepts that are affected when patients have elimination problems self-concept changes over one's lifespan and includes body image self-esteem roles and identity the urinary system is affected by many factors both as part of and outside of the urinary tract urinary elimination problems are common in all health care settings urinary elimination is private it is important when caring for patients from diverse cultures and religions to incorporate these practices into the plan of care using sensitivity and awareness of factors that may impact the patient's care when dealing with urinary elimination problems some cultures may have specific beliefs and practices related to elimination privacy and gender specific care because of the personal nature and cultural practices surrounding elimination urinary problems such as incontinence often are not discussed with medical professionals when the kidneys become infected or inflamed they can become tender and cause flank pain the bladder routinely rests below the symphysis pubis when the bladder is distended with urine urine the bladder will rise above the symphysis pubis along the midline of the abdomen a very full bladder may as stand may extend as far as the umbilicus careful and sensitive inspection of the external genitalia and the urethral meatus will provide important data that may indicate inflammation and infection assessment of skin exposed to moisture especially urine needs to occur at least daily and more often if incontinence is occurring to understand the early signs of skin damage that can be related to moisture the nurse should observe for erythema in areas exposed to moisture skin erosion and patient complaints of a burning or itching pain assessment of intake and output is a way to evaluate bladder emptying renal function as well as fluid and electrolyte balance urinary output is a key indicator of kidney and bladder functioning a change in urine volume can be a significant indicator of fluid imbalance kidney dysfunction or decreased blood volume the color of urine routinely ranges from pale straw to amber color depending on its concentration urine is routinely more concentrated in the morning or with fluid volume deficits the noise the clarity of routine urine appears transparent at the time avoiding urine that stands several minutes will become cloudy urine has a characteristic odor of ammonia the more concentrated the urine the stronger the odor consider the procedure of palpating the bladder to detect bladder distension every two hours on the even hours also think about the patient's voiding pattern consider the volume at each voiding the frequency the number of times of the day as well as the history of any changes a young girl is having problems urinating postoperatively you remember that children may have trouble voiding in bathrooms other than their own in a urinal while lying in bed in the presence of a person other than one of their parents the answer is d in the presence of a person other than one of their parents the ph of urine should be 4.6 to 8.0 the specific gravity of urine should be 1.005 to 1.030 for nursing diagnosis the nurse will use critical thinking to reflect on their knowledge of previous patients apply knowledge of urinary function and the effect of the disorders review assessment findings to make a specific nursing diagnosis while planning for care be sure to include the patient when determining goals and outcomes the goals for the patient need to be realistic and be something that the patient is willing to work on expected outcomes for this patient could include urinary elimination urinary continence and symptom severity consider the patient will void more than 150 ml each time the patient will verbalize no episodes of dribbling or incontinence the patient will verbalize relief of lower abdominal discomfort for health promotion and restoration think about patient education for a healthy bladder we teach our patients to maintain adequate hydration they need to drink six to eight glasses of water every day and spread it out evenly throughout a day they need to avoid or limit drinking beverages that contain caffeine to decrease nocturia they should avoid drinking two hours before they go to bed they should not limit fluids if they experience incontinence because concentrated urine may irritate the bladder and increase bladder symptoms the patient needs to keep good voiding habits women should sit back on the toilet seat avoid hovering over the toilet and make sure that the feet are flat on the floor they should void at regular intervals usually every three to four hours avoid straining when voiding or making bowel movements take enough time to empty the bladder completely the patient should keep the bowels regular a rectum full of stool may irritate the bladder causing urgency and frequency the patient should prevent urinary tract infections women cleanse the perineum from front to back after each voiding and bowel movement only wear cotton undergarments drink adequate amount of water to make pale yellow urine shower or bathe regularly a is a male urinal and b is a female urinal consider rationales for the interventions scheduled toileting is the primary behavioral intervention that is used for chronic retention and to reduce bladder capacity providing a record of urinary output is important to confirm voiding in small amounts relaxing in a bath eases discomfort and induces micturation patients with acute illness surgery or impaired function of the urinary tract may require more invasive interventions that support urinary elimination urinary catheterization is the placement of a tube through the urethra into the bladder to drain urine this has a risk of catheter-associated urinary tract infection the difference among urinary catheters is related to the number of catheter lumens the presence of a balloon to keep the indwelling catheter in place the shape of the catheter and a closed drainage system urinary catheters are made with one two three lumens a catheter should be chosen based on factors of latex allergy history of catheter encrustation anatomic factors and susceptibility to an infection indwelling catheters are made of latex or silicone latex catheters with special coating may reduce urethral irritation silicone catheters have a larger internal diameter and may be helpful in patients who require frequent catheter changes as a result of incrustation intermittent and straight catheters are made of rubber which are softer and more flexible or polyvinyl chloride known as pvc the size of a urinary catheter is based on the french scale which reflects the internal diameter of the catheter most adults with an indwelling catheter should use a size 10 to 12 french for women and 12 to 14 french for men to maximize trauma and the risk of an infection indwelling catheters come in a variety of balloon sizes from three milliliter balloons for a child to a 30 milliliter balloon the size of the balloon is usually printed on the catheter port the recommended balloon size for an adult is a 10 milliliter balloon the balloon is 5 milliliters and requires 10 milliliters to fill completely an indwelling catheter is attached to a urinary drainage bag to collect the continuous flow of urine this is a closed drainage system and tubing connections should not be separated to avoid introducing any pathogens patients with indwelling catheters require regular perineal hygiene especially after a bowel movement to reduce the risk for catheter associated urinary tract infection the patency of the indwelling catheter should be maintained it may be necessary to irrigate a flood or irrigate or flush a catheter with sterile solution however irrigation does pose the risk of causing a urinary tract infection and thus meat must be done maintaining a closed urinary drainage system the centers for medicare and medicaid services identified catheter-associated urinary tract infections as a never event the prompt removal of an indwelling catheter after it is no longer needed is a key intervention that has proven to decrease the incidence and the prevalence of hospital acquired urinary tract infections superpubic catheter is a urinary drainage tube insect inserted surgically into the bladder through the abdominal wall above the symphysis pubis an external catheter also called a condom catheter or penile sheath is a soft pliable condom-like sheath that fits over the penis providing a safe and non-invasive method to contain urine after surgery a patient with an incontinent urinary diversion must wear a pouch to collect the effluent or the drainage the pouch will keep the patient clean and dry protect the skin from damage and provide a barrier against odor techniques that can improve control over bladder emptying and restore some degree of urinary continence are pelvic floor exercises these techniques are commonly referred to as behavioral therapy and our first first-line treatment for stress urge and mixed incontinence when evaluating the plan of care the nurse should always assess the patient's expectations to ensure that they have been met what should sandy put in documentation related about this stage what patient responses would be consistent with the achievement of each outcome consider dribbling episodes and sense of urgency are relieved the urinary output is greater than 150 milliliters with each void the lower abdominal discomfort is absent consider teaching strategies that you would use with this patient you would need to establish a rapport with the patient you would also want to distinguish what information the patient already knows related to good practices for urinary health you would want to make sure that you use correct terms for the anatomy but explain it to the patient so the patient understands provide visual diagrams and written materials instruct the patient and observations to make regarding urinary output instruct the patient in adequate fluid intake discuss how the patient will obtain intake and output at home reinforce correct perineal hygiene measures when working with the urinary system remember that we need to use surgical asepsis especially when we are putting in a foley catheter we want to make sure that we know the patient's allergies so that there's no allergy to latex or potential allergy to latex you want to make sure that there's no allergy to betadine or iodine