Chapter 28: Urinary Elimination

What are the functions of the kidneys?

Answer: Kidneys have the following functions: Primary functions -The kidneys filter metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine. -The kidneys also help to regulate blood volume, blood pressure, electrolyte levels, and acid-base balance by selectively reabsorbing water and other substances. Secondary functions -Produce erythropoietin -Secrete the enzyme rennin -Activate vitamin D3 (calcitrol)

What types of medications are associated with urinary retention?

Answer: Medications with anticholinergic effects may lead to urinary retention.

Identify at least three methods for determining whether hydration is adequate and urine output is within normal limits.

Answer: Methods for determining whether hydration is adequate and urination is normal include the following: -The person voids 1,500 mL in a 24-hour period in five to six voids. -An infant has 8 to 10 wet diapers per day. -For most adults, pale to clear urine indicates adequate hydration.

Write at least two nursing diagnostic statements that would be appropriate for Marlena in the Meet Your Patient scenario (in Volume 1).

Answer: Numerous answers are possible, including the following: Impaired Urinary Elimination r/t complaints of frequency and dysuria Anxiety r/t urinary urgency and discomfort

What types of conditions or surgeries are associated with a high incidence of altered urination?

Answer: Patients with surgeries or pathology involving the genitourinary tract have a high incidence of altered urination.

What are the key elements of a physical assessment for a client with urination problems?

Answer: Physical assessment for urinary elimination includes examination of the kidneys, bladder, urethra, and skin surrounding the genitals. -Kidneys. Examine the kidneys by assessing for costovertebral angle tenderness (CVAT). -Bladder. Assess the bladder with inspection, palpation, and percussion. Begin the assessment by observing for swelling of the lower abdomen. Lightly palpate the lower abdomen to define the bladder margin. Observe the patient's response to palpation, noting any signs of tenderness or discomfort. Next, percuss the area. A distended bladder that has risen into the abdomen produces a dull sound, as opposed to the normal tympanic sound of intestinal air. Correlate the findings with data about the client's fluid intake and voiding. -Urethra. Assess the urethra by inspecting the urethral orifice. Look for erythema, discharge, swelling, or odor. These are all signs of infection, trauma, or inflammation. -Perineal area. Inspect the skin in the perineal area for signs of breakdown or irritation.

When caring for a client with an indwelling catheter, you notice sandy particles around the urethral meatus. What should you do?

Answer: Sandy particles are signs of encrustation and indicate the catheter should be replaced. Provide perineal care to the patient and obtain an order for replacement of the catheter from the primary care provider.

What Are the Main Points in This Chapter?

-The urinary system consists of two kidneys, two ureters, the urinary bladder, and the urethra. -The kidneys filter nitrogen and other metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine. -The bladder has a normal average storage capacity of 500 mL (1 pint), but it may distend, when needed, to a capacity twice that amount. -Voiding occurs when contraction of the detrusor muscle pushes stored urine through the relaxed internal urethral sphincter into the urethra. -The kidneys produce urine at a rate of approximately 60 mL per hour, or 1,500 mL per day. -Most people urinate about five to six times per day. -Voiding and control of urination require normal functioning of the bladder and the urethra, as well as an intact brain, spinal cord, and nerves supplying the bladder and urethra. -As an adult ages, the number of functional nephrons gradually decreases, along with the ability to dilute and concentrate urine. The potential volume of the bladder also decreases as the bladder wall loses elasticity; thus, older adults need to urinate more frequently. -Substances that contain caffeine act as diuretics and increase urine production. -A diet high in salt causes water retention and decreases urine production. -Medications with anticholinergic effects inhibit the free flow of urine and may contribute to urinary retention. -An adequately hydrated adult produces clear yellow urine. -Concentrated urine is darker in color, but dilute urine can appear colorless. -A clean-catch urine specimen is preferred for many diagnostic tests. To collect this specimen, the client must cleanse the genitalia before voiding and collect the sample in midstream. -Sterile urine specimens may be obtained by inserting a catheter into the bladder or withdrawing a sample from an indwelling catheter. -Twenty-four-hour urine collection requires collection of all urine voided in the time period. The start time of the 24-hour collection begins when the first-voided urine is discarded. -A routine urinalysis is one of the most commonly ordered laboratory tests. It is used as an overall screening test as well as an aid to diagnose renal, hepatic, and other diseases. -Normal urine is free of bacteria, viruses, and fungi. -Urinary tract infections are often caused by the introduction of Escherichia coli (E. coli), which normally live in the colon, into the urethra and bladder. -Urinary retention is an inability to empty the bladder. It may occur because of obstruction, neurological problems, infection, surgery, medications, or anxiety. -Urinary catheterization is the introduction of a pliable tube (catheter) into the bladder to allow drainage of urine. -Urinary incontinence (UI) is a lack of voluntary control over urination. Nurses can independently perform the primary interventions to manage UI. -A urinary diversion is required when the bladder must be removed or bypassed. There are three options: a conventional urostomy or ileal conduit, a continent urinary reservoir, or a neobladder. -A patient with a urinary diversion requires physical and psychological care. The goal is to have the patient become comfortable with his changed body and assume self-care.

are caring for a patient on a hospital unit from 0700 to 1200. Based on the following information, calculate the I&O and comment on your findings. Receiving IV fluid at 125 mL/hr 0800 breakfast—4 oz juice, toast, scrambled eggs, 8 oz coffee 0930—3 oz water 0700 to 1200—wound drainage: 360 mL 0700 to 1200—urine output per indwelling catheter: 180 mL

Answer: Intake. The patient's fluid intake is 1,075 mL in 5 hours; this includes IV fluid ands oral fluid. Output. The patient's fluid output is 540 mL in 5 hours; this includes urine and wound drainage. Comments. There is a +535 mL balance, although the urine output is low at an average of 36 mL/hr.

A patient who underwent surgery for removal of a pituitary tumor develops a condition in which the kidneys are unable to conserve water and the quantity of urine voided increases. Which urine specific gravity would the nurse expect to find in the patient with this disorder? 1) 1.001 2) 1.010 3) 1.025 4) 1.030

Answer: 1) 1.001 Rationale: The patient with diabetes insipidus would have a low specific gravity, such as 1.001. This indicates dilute urine that results from poor concentrating ability of the kidneys. Normal urine specific gravity ranges from 1.010 to 1.025. A specific gravity of 1.030 indicates concentrated urine or deficient fluid volume (dehydration).

What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

Answer: 1) Decreased glomerular filtration rate Rationale: Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute. Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro-blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging. Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging. Renal mass (weight) decreases over time, starting around age 30 to 40.

When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the penis with an antiseptic wash. Which step should she take next? 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. 2) Ask the patient to bear down as though trying to void. 3) Slowly insert the end of the catheter into the urinary meatus. 4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.

Answer: 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. Rationale: The steps of the procedure for inserting an indwelling urinary catheter are as follows: The nurse should gently insert the tip of the prefilled syringe into the urethra and instill the lubricant. Then the nurse should ask the patient to bear down as though trying to void, as she slowly inserts the end of the catheter into the meatus. She should continue to insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows. When urine appears, she should advance the catheter 1 to 2 inches (2.5 to 5 cm) more. She should hold the catheter securely with her dominant hand while the urine flows. After urine flows, she should stabilize the catheter's position in the urethra and use the other hand to pick up the saline-filled syringe and inflate the catheter balloon.

A patient is admitted with pyelonephritis. Which anatomic structure is affected by this disorder? 1) Kidneys 2) Bladder 3) Urethra 4) Prostate gland

Answer: 1) Kidneys Rationale: Pyelonephritis is an infection of the kidneys. Cystitis is an infection involving the bladder. An infection of the urethra is known as urethritis. Prostatitis is an infection involving the prostate gland.

A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.

Answer: 1) Palpating the bladder height. 3) Performing a bladder scan. 4) Asking the patient about his recent voiding history. Rationale: The nurse should palpate the bladder for distention. A bladder scan will yield a more accurate measurement of the postvoid residual urine. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care. A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection. Cranberry juice is sometimes used to in an effort to prevent urinary tract infection, although there is conflicting research to support this action. Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder and is usually unnecessary if the nurse has access to a portable bladder scanner.

Which urinary system structure is largely responsible for storing urine? 1) Kidney 2) Bladder 3) Ureters 4) Nephrons

Answer: 2) Bladder Rationale: The urinary bladder is a sac-like organ that receives urine from the ureters and stores it until discharged from the body. The kidneys filter metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine. The ureters transport urine. The nephrons form urine.

Which medication will the primary care provider will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

Answer: 2) Furosemide Rationale: Furosemide (Lasix) is a loop diuretic that increases urine elimination. It works by limiting the reabsorption of water in the renal tubules. Digoxin (Lanoxin) increases the force of contraction by the heart. It is also prescribed for treatment of heart failure. Lovastatin (Mevacor) is a cholesterol-lowering agent. Atorvastatin (Lipitor) is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart disease, the medication is used to reduce cholesterol in the blood—not to promote diuresis to reduce the demand on the heart and backflow into the lungs.

The nurse is obtaining the history of a newly admitted patient. Which element in the history places the patient at risk for urinary tract infection? 1) Hypertension 2) Hypothyroidism 3) Diabetes mellitus 4) Hormonal contraceptive use

Answer: 3) Diabetes mellitus Rationale: Diabetes mellitus places the patient at risk for urinary tract infection because glucose in the urine provides a medium favorable for bacterial growth. Hypertension, hypothyroidism, and hormonal contraceptive use are not directly related to an increased risk for urinary tract infection.

The parent of a 7-year-old son brings the child to the pediatric care provider to discuss her child's nighttime bedwetting. She reports he has never achieved consistent dryness at night. What is the nurse's best response to the mother's concern? 1) "We'll start medication right away to control it." 2) "Family history is not associated with bedwetting." 3) "We will look for a urinary tract infection." 4) "Wait it out. Your son will likely outgrow it."

Answer: 4) "Wait it out. Your son will likely outgrow it." Rationale: Based on the history, the nurse understands the condition is nocturnal enuresis because the child has not yet achieved dryness at night at an age when continence would be expected. Nocturnal enuresis is most common among boys. Ninety-five percent of children outgrow it by age 10. Nighttime bedwetting runs in families. So if one parent experienced nocturnal enuresis as a child, then the chances that the child will also have trouble with achieving continence at night will be likely. Pharmacological intervention can be useful for older children, particularly when the child is not sleeping at home. However, prior to age 8 or 10, medication is not indicated. Frequency and urgency and burning are signs of a urinary tract infection. These symptoms are most noticeable during the day (not night). Nocturnal enuresis occurs without the person realizing that he emptied the bladder.

Which blood level is commonly tested to help assess kidney function? 1) Hemoglobin 2) Potassium 3) Sodium 4) Creatinine

Answer: 4) Creatinine Rationale: The nurse would examine laboratory results for blood urea nitrogen and creatinine to assess kidney function. Hemoglobin, potassium, and sodium levels can be affected by kidney disease, but they do not directly assess kidney function.

The nurse is teaching an older female patient how to manage stress incontinence at home. She instructs her to contract her pelvic floor muscles for at least 10 seconds followed by a brief period of relaxation. What is this intervention called? 1) Prompted voiding 2) Crede technique 3) Valsalva maneuver 4) Kegel exercises

Answer: 4) Kegel exercises Rationale: Kegel exercises strengthen the pelvic floor muscles that support the uterus, bladder, and bowel. Doing Kegel exercises regularly can reduce urinary incontinence. These exercises involve tightening and relaxing the muscles around the vaginal area. Prompted voiding is a part of a bladder-training program in which the person learns to void based on a schedule, rather than to empty the bladder. The Crede technique is applying manual pressure with your hands to the top portion of the bladder to initiate a urine flow. The Valsalva is the maneuver in which a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose, for example, in strenuous coughing, straining during a bowel movement, or lifting a heavy weight.

What quantity of urine in the bladder will stimulate the urge to void?

Answer: Approximately 200 to 450 mL of urine in adults (50 to 200 mL in children) are sufficient to stimulate the urination reflex. Less may be required in older adults.

A patient's urine specific gravity has been reported at 1.035. Which of the following nursing actions would be appropriate? A. Start an IV of normal saline at 150 mL per hour. B. Encourage the patient to increase fluid intake. C. Insert a straight catheter to assess for urinary retention. D. Obtain an order for fluid restriction from the physician.

Answer: B. Encourage the patient to increase fluid intake. Rationale: A specific gravity of 1.035 would indicate concentrated urine, indicating the possibility of dehydration. Starting an IV of normal saline is not an independent nursing action.

The nurse knows that the patient has understood teaching related to urinary incontinence when the patient states which of the following? A. "I'll just get those disposable pads because there is nothing to be done." B. "I'll limit my fluid intake so that I won't dribble so much." C. "I will do my Kegel exercises every day." D. "I'm going to have surgery, and the doctor will make a neobladder."

Answer: C. "I will do my Kegel exercises every day." Rationale: Kegel exercises help to strengthen the pelvic floor muscles and help to prevent and treat some types of incontinence. You would not want the patient to decrease fluid intake unless excessive (> 3,000 mL) because this would lead to concentrated urine and risk for UTI. A neobladder may be created when the bladder is removed.

Mrs. Sanchez is awaiting surgery for a right hip fracture. The physician suspects that Mrs. Sanchez has a urinary tract infection. The nurse anticipates that the physician will order which of the following? A. Freshly voided urine specimen in the morning B. Clean-catch specimen C. Sterile urine specimen D. 24-hour urine collection

Answer: C. Sterile urine specimen Rationale: For most patients, a clean-catch specimen would be ordered. However, because Mrs. Sanchez would need to use a "fracture pan," it is very likely that the specimen would be contaminated during collection. As a result, a straight catheterization will be needed.

_________________________ is the application of gentle, manual pressure over the bladder to promote bladder emptying.

Answer: Crede's maneuver

The nurse notes that there has only been 100 mL of urine output from his patient's Foley catheter in 6 hours. The nurse should first do which of the following? A. Instruct the patient to drink two glasses of water. B. Call the doctor immediately. C. Irrigate the Foley catheter with 30 mL of sterile saline. D. Assess the catheter tubing and the patient's abdomen.

Answer: D. Assess the catheter tubing and the patient's abdomen. Rationale: The nurse should first determine whether urine is being retained in the bladder. This can be accomplished through palpation of the bladder and/or checking the catheter tubing for kinks.

What common medications increase the amount of urine voided?

Answer: Diuretics increase urine output.

How often should the urine collection bag be emptied?

Answer: Empty the urine collection bag at least every 8 hours, or more often if it is full, to make it more convenient for the patient to ambulate. For other care of indwelling catheters, refer to Procedure 28-2, in Volume 2.

The nurse should call the physician immediately if a patient's urostomy stoma is red in color.

Answer: False Rationale: This is a normal finding.

Why is intermittent catheterization preferred for patients who must be catheterized over lengthy periods of time?

Answer: For patients who must be catheterized over lengthy periods of time, intermittent catheterization is preferred because it carries a substantially lower risk of infection than an indwelling catheter.

Describe the difference between a catheter used for straight catheterization and one used for ongoing drainage.

Answer: The catheters have the following differences: -A straight catheter has a single lumen and is inserted for brief periods for immediate drainage of the bladder (e.g., to obtain a sterile urine specimen, to measure post-void residual volume, or to relieve temporary bladder distention). -An indwelling catheter (Foley or retention catheter) is used for continuous bladder drainage and may have two or three lumens. The first lumen drains urine, the second lumen is used to inflate the balloon that holds the catheter in place, and a third lumen may be used for bladder irrigation.

What actions should you take before inserting a catheter?

Answer: The following actions should be taken before inserting a catheter: -Verify the order. -Gather appropriate supplies. -Explain the procedure to the patient. -Answer any questions the patient may have. -Provide privacy.

Identify activities that promote normal urination patterns.

Answer: The following activities promote normal urination patterns: -Provide privacy. -Assist with positioning. -Position the patient in his preferred position whenever possible. -Provide a bedpan, urinal, or bedside commode if the patient cannot ambulate to the bathroom. -Facilitate toileting routines; determine the patient's usual voiding pattern and assist him to the toilet at these times and upon request. -Promote adequate fluids and nutrition; encourage an intake of 8 to 10 large glasses of fluid daily for patients without health concerns that limit their fluid intake. -Assist with perineal hygiene if the patient cannot provide self-care.

What should you discuss with your client when performing a nursing history focused on urinary elimination?

Answer: The following items should be part of a nursing history focused on urinary elimination: -Normal urination pattern -Appearance of urine -Changes in urination habits or urine appearance -History of urination problems -Use of urination aids -Lifestyle questions -Presence of urinary diversions, if any For specific questions, refer to Assessment Guidelines and Tools, Urinary Elimination History Questions, in Chapter 28 of Volume 2.

What role do the ureters, bladder, and urethra play in urinary elimination?

Answer: The structures of the urinary system have the following roles: -The ureters transport urine from the kidneys to the bladder. -The bladder stores urine until it is excreted. -The urethra transports urine from the urinary bladder to the body exterior.

Identify the major structures of the urinary system.

Answer: The urinary system comprises the following major structures: -Two kidneys -Two ureters -Bladder -Urethra

Explain how to collect a clean-catch urine specimen.

Answer: To collect a clean-catch specimen, the client must cleanse the genitalia before voiding and collect the sample in mid-stream. For detailed instructions, Go to Procedure 28-2A, in Volume 2.

It is important for the nurse to assess the results of the serum blood urea nitrogen and serum creatinine lab tests for the patient receiving certain chemotherapy agents.

Answer: True Rationale: Chemotherapy agents can also be nephrotoxic.

Briefly describe how urine is formed.

Answer: Urine is formed in the nephrons. The renal arteries bring blood to the kidneys and into the glomeruli. Blood pressure forces plasma, dissolved substances, and small proteins out of the porous glomeruli into the Bowman's capsule to form a liquid called filtrate. The filtrate moves from Bowman's capsule into the tubular network of the nephrons, where 99% of the fluid is reabsorbed. About 1% of filtrate returns, as urine, to the collecting tubule, which transports it into the ureters.

A/an _________________________ is a type of urinary diversion that involves implanting the ureters into a small segment of the small intestine, which is then brought to the abdominal wall where a stoma is created.

Answer: conventional urostomy or ileal conduit

Percussion of the _________________________ that results in pain or discomfort could indicate the presence of an inflammatory process in the kidney.

Answer: costovertebral angle

If a child is experiencing involuntary urination after the age of 5 or 6, he may have a condition known as _________________________.

Answer: enuresis

A _________________________ is an instrument that is used to measure the specific gravity of urine.

Answer: refractometer

Esherichia coli is an intestinal bacterium that is frequently responsible for urinary tract infections.

True