URINARY ELIMINATION

(MIDTERM)
ANATOMY AND PHYSIOLOGY

1. The major role of the urinary system is to maintain hemostasis by maintaining body fluid
composition and volume.
2. The components of the urinary system are follows: kidneys, ureter, urinary bladder and
urethra.

KIDNEYS

1. The kidneys are two bean-shaped organ located retroperitoneally at the level of the twelfth
thoracic and third lumbar vertebra.
2. The right kidney is slightly lower than the left kidney due to the presence of liver on the right
side of the abdomen.
3. The kidneys are divided into renal cortex, medulla and pelvis. The medulla is composed of
series of pyramind.
4. The functional units of the kidneys are the nephrons. The nephron is composed of glomerulis
and the renal tubules
5. The glomerulus is a tuft of semi-permeable capilliaries, surrounded by the Bowman’s capsule.
6. The three regions of the renal tubules are follows: proximal convulated tubules, loop of henle
and the distal convoluted tubules.
7. The primary function of the nephrons is formation of urine
8. About 1,2000 mls of blood flows to the kidneys per minute which is 20-25% of the cardiac
output.
9. Through the formation of urine, the kidneys remove waste products from the body, regulate
fluid volume, maintain electrolyte concentration, blood pressure and pH within the body.

URETER

1. The ureter are two small tubes about 25 cm long. They transport urine from the renal pelvis to the
urinary bladder.
2. The ureter enter the urinary bladder obliquely and is guarded by ureterovesicular sphincter.
These two factors prevent reflux of urine as the bladder contracts

URINARY BLADDER

1. The urinary bladder serves as reservoir for urine

2. It is composed of three layers of detrusor muscles. Contraction of these muscles expels urine
from the bladder.
3. The bladder is guarded by internal urethral sphincter in the junction of its opening into the urethra.
4. The trigone is a triangular region in the floor of the bladder that is marked by the openings for two
ureters and the internal urethral orifice.
5. The approximate maximum capacity of the bladder is 1,000 mls. of urine.

URETHRA

1. The urethra is the passageway of the urine into the external environment.
2. The internal urethral sphincter is an involuntary muscle while the external urethral sphincter is
voluntary muscle.
3. The female urethra is 1 ½ to 2 ½ inches while the male urethra is 5 ½ to 6 ½ inches up to 8
inches in length. The shorter urethra among females increase propensity to urinary tract
infection.

URINE FORMATION
 The three steps of formation of urine by the kidneys are as follows:

1. Glomerular Filtration
 Water and solutes move from the blood to the glomerular capsule. The fluid that
enters the capsule is called glomerular filtrate.
2. Tubular absorption
 It is the movement of the substances from the filtrate in the kidney tubules into the
blood in the peritubular capillaries. Only 1 percent of the filtrate remains in the tubules
and become a urine.
 Water and other substances that are useful to the body are reabsorbed. Water is
reabsorbed by osmosis, while most solutes are reabsorbed by active transport
3. Tabular secretion
 It is the transport of substances from the blood into the renal tubules. Potassium and
hydrogen are primarily eliminated from the body. Ammonia, uric acid, some drug
metabolites are likewise eliminated.

MICTURATION

- It is the act of expelling urine from the bladder. (Also urination or voiding). The parasymphatetic
nervous system initiates voiding. Whereas, the sympathetic nervous system inhibits voiding. The
micturition reflex is involuntary, but it can be inhibited by high brain centers.

NORMAL CHARACTERISTICS OF THE URINE

Color: amber/straw
Odor: aromatic-upon voiding
Transparency: clear
pH: slightly acidic ( range 4.6- 8; average of 6)
Specific gravity: 1.010-1.025 (this is measured by urinometer)

Problems in Urinary Elimination

A. Altered Urine Composition

 RBC Hematuria
 WBC Urinary Tract of
Infection
 Pus Pyuria
 Bacteria Bacteriuria
 Albumin Albuminuria Diabetic Ketoacidosis
 Protein Proteinuria
 Casts Cylindriuria
 Glucose Glycosuria
 Ketones Ketonuria

B. Altered Urine Production

1. Polyuria. The production of excessive amount of urine, such as more than 100 ml/hr or 2500
ml/day ( also diuresis)
2. Oliguria. The production of decreased amount of urine, such as less than 30 ml/hr or less
than 500 ml/24 hours
3. Anuria. The absence of production of urine by the kidneys such as a 0 to 10 ml/hr ( also
urinary suppression)

C. Altered Urinary Frequency

1. Frequency. Voiding at frequency intervals
 2. Nocturia. Increased frequency at night
3. Urgency. The strong feeling that the person wants to avoid. There may or may not be a great
amount of urine in the bladder
4. Dyrusia. Voiding that is either painful or difficult
5. Hesitancy. Difficulty in initiating voiding
6. Enuresis. Repeated involuntary voiding beyond 4-5 years of age
7. Pollakuria. Frequent, scanty urination
8. Urinary incontinence
a. Total incontinence. A continuous and unpredictable loss of urine
b. Stress incontinence. The leakage of less than 50 ml of urine as a result of sudden
increase in intra-abdominal pressure, e.g. when one coughs, sneezes, laughs or exerts
physically
c. Urge incontinence. Follows a sudden strong desire to urinate and leads to involuntary.
d. Functional incontinence. The involuntary unpredictable passage or urine
e. Reflex incontinence. Is an involuntary loss of urine occurring at somewhat predictable
intervals when specific bladder volume is reached.

9. Retention. The accumulation of urine in the bladder with associated inability of the bladder to
empty itself.

Clinical Signs of Urinary Retention

a. Discomfort in the pubic area
b. Bladder distention ( palpation and percussion)
 Smooth, firm, ovoid mass at the suprapubic area
 Mass arising out of the pelvis
 Dullness on percussion
c. Inability to void or frequent voiding of small volumes ( 25-30 ml at a time)
d. A disproportionately small amount of output in relation to fluid intake
e. Increasing restlessness and feeling of need to void.

NURSING INTERVENTION TO INDUCE VOIDING

1. Provide privacy. This is most effective nursing measure to induce voiding

2. Provide fluids to drink
3. Assist the patient in the anatomic position of voiding
4. Serve clean, warm and dry bedpan ( female) or urinal ( male)
5. Allow patient to listen to the sound of running water
6. Dangle fingers in warm water
7. Pour warm water over the perineum
8. Promote relaxation
9. Provide adequate time for voiding
10. Perform Crede’s maneuver as ordered. This is done by apply pressure on the suprapubic area
11. Administer cholinergics, e.g. Urecholine,( Bethanecol )as ordered
12. Last resort: Urinary catheterization. This is the last resort because it is one of the most common
causes of nonsocomial infection

RELATED SKILL: Urinary Catheterization

 Single catheterization: Straight/ Nelaton Catheter
 Retention Catheterization: 2 way foley catheter
 Continuous Bladder Irrigation: ( Cystoclysis): 3 foley catheter

PURPOSES
1. To relieve bladder distention
2. To instill medication into the bladder
3. To irrigate the bladder
4. To measure hourly urine output accurately
5. To collect urine specimen
6. To measure residual urine. Residual urine is the amount of urine retained in the bladder after
a forceful voiding
7. To maintain continence among incontinent clients
8. To promote healing of the genito-urinary structures postoperatively
NURSING INTERVENTIONS IN URINARY CATHETERIZATION

1. Verify the doctor’s order and identify the client

2. Explain the procedure and purpose to client
3. Provide privacy. Invasive procedures cause feelings of embarrassment
4. Promote relaxation to relax uretheral sphincter
5. Practice strict asepsis to prevent ascending UTI
6. Do perineal care before the procedure. To minimize microorganism at the external genitals
7. Use appropriate size of catheter. To prevent trauma to the mucous membrane
 Male: Fr 16-18
 Female: 12- 14
8. Have adequate lighting. To visualize urethral meatus
9. Position of the patient during urinary catherization
 Male: supine, legs abducted and extended
 Female: dorsal recumbent position
10. Don sterile gloves. Inflate the balloon of the catheter with air to check that it is intact then deflate
11. Locate the urinary meatus properly
 Male: at the tip of the glans penis
 Female: between the clitoris and vaginal orifice
12. Cleans urinary meatus with antiseptic solution using downward stroke
13. Lubricate catheter with water soluble lubricant before insertion to reduce friction and prevent
trauma
14. Insert catheter with water soluble lubricant before insertion to reduce friction and prevent trauma
15. Length of catheter insertion:
 Male: 6-9 inches
 Female: 3-4 inches
16. During insertion of the catheter in male, hold the penis at 90 degree angle or perpendicular to the
body. To straighten the urethra and facilitate catheter insertion
17. If the purpose of catheterization is to relieve bladder distention, practice GRADUAL
DECOMPRESSION to prevent shock, hemorrhage, or bladder atony. Gradual decompression
may be done by the following actions:
 Empty the bladder slowly by pinching the catheter to reduce the size of the lumen
 Elevate the urine receptacle at the level of symphysis pubis to slow down expulsion of
urine
 Do not remove more than 1,000 ml of urine at a time
18. For retention catheterization, inflate the balloon with 5-ml, sterile NSS, properly inflated in the
bladder
19. Gently pull on the catheter. If resistance is felt, the catheter balloon is properly inflated in the
bladder.
20. Anchor catheter properly
 Male: laterally or upward over the lower the abdomen to prevent penoscrtotal pressure
 Female: inner aspect of the thigh, providing enough “give”, so it will not pull down when
the legs move.
21. Attach the drainage bag to the bed frame, ensuring that tubing does not fall into dependent loops.
Dependent loops fill with the urine and can prevent free drainage of urine.
22. Keep the client comfortable
23. Do after care equipment and articles
24. Make relevant documentation

NURSING INTERVENTIONS FOR CLIENTS WITH RETENTION CATHETER

1. Practice asepsis. Proper handwashing should be done before and after manipulating the device,
e.g. emptying of the urinary drainage bag. To increased infection.
2. Increase fluid intake (3,000 ml/day). To enhance excretion of microorganism
3. Acidity urine ( diet: meat, fish, fowl, eggs and cereals) acidic urine inhibits proliferation of
microorganism
4. Maintain closed drainage system. Do not detach catheter from the connecting tubing,
unnecessarily.
5. Meticulous perineal care. To prevent ascending UTI.
6. Ensure patency of urinary catheter. Avoid kinks. Irrigate with sterile NSS ordered
7. Ensure the gravity of urine maintained. Hold the urinary drainage bag below the level of the
bladder when ambulating
8. Monitor I and O. This is an objective parameter for kidney function
9. Change urinary catheter tubing and urinary drainage bag when sediment accumulates, if leakage
is present or if a strong odor is event.

NURSING INTERVENTION FOR CLIENTS WITH URINARY INCONTINENCE

1. Bladder training Program. Determine the client’s voiding pattern or establish a regular time ( e.g.
every 1-2 hours during the day and evening before retiring at night, every 4 hours at night)
2. Lengthen the intervals of voiding once the client’s voiding can be controlled.
3. Regulate fluid intake, particularly before the client retires. To prevent nocturia
4. Insert hub of the syringe into balloon inflation port and draw out all liquid (NSS). The balloon must
be completely deflated to prevent trauma to the urethra as the catheter is removed.
5. Instruct the client to inhale and then pinch and remove the catheter slowly carefully as the client
exhales. Breathing provides distraction and exhalation prevents tightening of abdominal and
perineal muscles as catheter is withdrawn. Pinching catheter prevents urine from dribbling onto
the bed linens.
6. After removal of catheter, allow the urine to drain into collection bag. Measure and record the
amount of urine remaining the collection in the collection bag.
7. Assess client’s perineum and meatus for any signs of redness or irritation.
8. Assist client to do perineal care and dry genitals. To ensure client discomfort
9. Discard contaminated equipment and articles in appropriate containers. To prevent contamination
of the environment.
10. Make relevant documentation
 Voiding should be expected within 6 to 8 hours from the time of removal of catheter.
Some dribbling of urine may be experienced
 Continue to assess input and output
 If the client has not voided in 8 hours, assess for urinary retention
 If the client has difficulty establishing, voluntary control of the voiding, notify the
physician. It may be necessary to reinsert the catheter or to perform in and out
( intermittent) catheterization
 INTRAVENOUS
 Direct IV, IV push and IV infusion
 Most rapid route of absorption of medication
 Predictable, therapeutic blood levels of medications can be obtained
 The route can be used for clients with compromised gastrointestinal function or peripheral
circulation

TYPES OF I.V.FLUIDS
1. Isotonic solution. Has the same concentration as the basal fluids.
e.g. D5W, NaCl 0.9%, plan Ringer’s lactate, plain Normosal M.
2. Hypotonic. Has lower concentration than the body fluids. E.g. NaCl 0.3%
3. Hypertonic. Has higher concentration than the body fluids. E.g. D10W, D50W, D5LR, D5NM

NURSING INTERVENTIONS

1. Verify the doctor’s order

2. Know the type, amount, and indication of IV therapy
3. Practice strict asepsis
4. Inform client and explain the procedure
5. PRIME I.V. tubing and explain the purpose
6. Clean the insertion site of I.V. needle from the center to periphery with alcoholized cotton
swab
7. Change I.V. tubing every 72 hours. To prevent contamination
8. Change/ alter needle insertion site every 72 hours. To prevent thrombophlebitis
9. Regulate I.V. every 15-20 minutes. To ensure administration of proper volume of I.V. fluid as
ordered
10. Observe for potential complications

COMPLICATIONS OF I.V. INFUSION

1. Infiltration. The needle is out of vein, fluids and accumulate in the subcutenous tissues
 Assessment
 Pain
 Swelling
 Skin is cold at needle site
 Pallor of the site
 Flow of IV rate decreases or stop
 Absence of backflow of blood into the tubing as the IV fluid is put down, or the
tubing is kinked
 Nursing Interventions
 Change the site of needle
 Apply warm compress. This will reabsorb edema, fluids, and reduce swelling
2. Circulatory Overload. Results from administration of excessive volume of IV fluids
 Assessment
 Headache  Increased venous
 Flushed skin pressure
 Rapid pulse  Coughing
 Increased BP  SOB ( Shortness of
 Weight gain breath)
 Syncope or faintness  Tachypnea
 Pulmonary edema  Shock
 Nursing Interventions
 Slow infusion to KVO ( Keep vein open-10 gtts/min)
 Place patient in high-fowler’s position. To ease breathing
 Administer diuretic bronchodilators as ordered

3. Drug Overload. The patient receives an excessive amount of fluid containing drugs.
  Assessment
Dizziness
Shock
Fainting
 Nursing intervention
 Slow infusion to KVO. Notify physician

4. Superficial Thrombophlebitis. It is due to overuse of a vein, irritating solutions or drugs, clot

formation, large bore catheters.
 Assessment
 Pain along the course of vein
 Vein may feel hard and cordlike
 Edema and redness at the needle insertion site
 Arms feel warmer than the other arm
 Nursing interventions
 Change IV site every 72 hours
 Use large veins for irritating fluids
 Stabilize venipuncture at area of flexion
 Apply cold compress immediately to relieve pain and inflammation; later follow
with warm compress to stimulate circulation and promote absorption
 Do not irrigate the IV fluids because this could push clot into systemic circulation

5. Air Embolism. Air manages to get into the circulatory system 5 ml of air or more causes air
embolism
 Assessment
 Chest, shoulder, or  Tachycardia
backpain  Increased venous
 Hypotension pressure
 Dyspnea  Loss of consciousness
 Cyanosis
 Nursing Interventions
 Do not allow IV bottle to “ run dry”
 “Prime” IV tubing before starting infusion
 Turn patient to left side in the Trendelenburg position. To allow air to rise in the
right side of the heart. This prevents pulmonary embolism.

6. Nerve Damage. May result from tying the arm too tightly to the splint.
 Assessment
 Numbness of fingers and hands
 Nursing Interventions
 Massage area and move shoulder through its ROM.
 Instruct the patient to open and close hand several times each hour
 Physical therapy may be required
 Apply splint with the fingers free to move

7. Speed Shock. May result from administration of IV push medications rapidly

 To avoid speed shock, and possible cardiac arrest, give most IV push medications
over 3 to 5 minutes
 BLOOD TRANSFUSION

Purposes:

1. To administer requires blood component by the patient

2. To restore the blood oxygen
3. To improve oxygen-carrying capacity of the blood

Nursing Interventions

1. Verify doctor’s order. Inform client and explain the purpose of the procedure
2. Check for cross- matching and blood typing. To ensure compatibility
3. Obtain and record baseline VS
4. Practice strict ASEPSIS
5. At least 2 nurses check the label of the blood transfusion
 Check the following:
 Serial number
  Blood component
 Blood type
 Rh factor
 Expiration data
 Screening tests ( VDRL for sexually transmitted diseases; HBsAg for hepatitis B;
malarial smear for malaria)
6. Warm blood at room temperature before transfusion. To prevent chills.
7. Identify client properly. Two nurses check the client’s identification
8. Use needle gauge 18 to 19. This allow easy flow of blood.
9. Use of BT set with filter. To prevent administration of blood clots and other particulates.
10. Start infusion slowly at 10 gtts/min. remain at the bedside for 15 to 30 minutes. Adverse reaction.
11. Monitor VS. altered VS indicates adverse reaction
12. Do not mix medications with blood transfusion. To prevent adverse effects
 Do not incorporate medication into the blood transfusion
 Do not use the blood transfusion line for IV push of medications
13. Administer 0.9% NaCL before, during or after BT. Never administer IV fluids with dextrose.
Dextrose causes hemolysis
14. Administer, BT for 4 hours ( whole blood, packed rbc). For plasma, platelets, cryoprecipitate,
transfuse quickly ( 20 minutes) clotting factors can easily be destroyed
15. Observe for potential complications. Notify physician

COMPLICATIONS OF BLOOD TRANSFUSION

1. Allergic Reaction. It is caused by sensitivity to plasma protein or donor antibody, which reacts
with recipient antigen.
 Assessment
 Flushing  Pruritus
 Rash, hives  Laryngeal edema, DOB
2. Febrile, Non- Hemolytic. It is caused by hypersensitivity to donor white cells, platelets or plasma
proteins. This is most symptomatic complication of BT.
 Assessment
 Sudden chills and fever  Headache
 Flushing  Anxiety
3. Septic Reaction. It is caused by transfusion of blood or components contaminated by bacteria
 Assessment
 Rapid onset of chills
 Vomiting
 Marked hypotension
 High fever

4. Circulatory Overload. It is caused by administration of blood volume at a rate greater than the
circulatory system can accommodate.
 Assessment
 Rise in venous pressure
 Dyspnea
 Crackles
 Distended neck vein
 Cough elevated BP
5. Hemolytic reaction. It is caused by infusion of incompatible blood products
 Assessment
 Low back (first sign).  Tachycardia
This due to  Flushing
inflammatory response  Tachypnea
of the kidneys to  Hypotension
incomplete blood  Bleeding
 Chills  Vascular collapse
 Feeling of fullness  Acute renal failure
NURSING INTERVENTIONS WHEN COMPLICATED OCCURS IN BLOOD TRANSFUSION

1. Stop blood transfusion immediately

2. Start an IV line ( 0.9% NaCl)
3. Collect urine specimen. To detect presence of bacteria, which may be causing the adverse
reaction to blood transfusion
4. Monitor VS
5. Send unused blood and BT set to the blood bank. For laboratory examination
6. Administer antihistamine, diuretics and bronchodilators
7. Make relevant documentation