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Course: Fundamentals of Nursing�Topic: Elimination I: Urinary

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Module Goals

Learners will be able to:

Identify factors that put a client at risk for alterations in urinary elimination.
Identify factors related to alterations in elimination across the lifespan.
Outline the data that must be collected for identification of alterations in urine elimination.
Identify basic diagnostic tests of urinary elimination.
Detail the nonpharmacologic measures to promote urinary elimination.

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Elimination

Ingested food and fluids are eliminated from the body through gastrointestinal and urinary system.
Nurses provide care for clients with commonly occuring elimination. alterations that include:

Urinary tract infections
Urinary incontinence
Urinary retention
Constipation
Diarrhea
Bowel incontinence

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Urinary System

Also referred to as renal system or urinary tract system.
Composed of:

Kidneys
Ureters
Bladder
Urethra

Purpose:

Eliminates waste from the body through urine.
Regulates blood volume and blood pressure.
Controls levels of electrolytes and metabolites.
Regulates blood pH.

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Terminologies for Urinary Assessment

Anuria: absence of urine output.

Defined by less than 50 mL of urine over a 24-hour period.
Typically found during kidney failure.

Oliguria: decreased urine output¹.

Defined as less than 0.5 mL of urine per kilogram per hour in adults and children¹.
Or, less than 1 mL of urine per kilogram per hour for infants¹.
May indicate dehydration, fluid retention, or decreasing kidney function.

Berry, 2020, as cited in Ernstmeyer & Christman, 2021

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Terminologies for Urinary Assessment

Dysuria: painful or difficult urination (voiding).

Burning, tingling, or stinging of the urethra and meatus while voiding¹.
Distinguished from bladder discomfort like suprapubic/retropubic pain, pressure, or discomfort that usually increases with bladder volume¹.
Urinary tract infection (UTI) is the most common cause for dysuria¹.

Polyuria is greater than 2.5 liters of urine output over 24 hours.

Diuresis.
Urine is typically clear with no color².
New polyuria may indicate a medical condition.

Michels & Sands, 2015
A.D.A.M. Medical Encyclopedia, 2021, as cited in Ernstmeyer & Christman, 2021

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Glossary:

Urinary Tract Infection: A condition in which bacteria invade and grow in the urinary tract (the kidneys, ureters, bladder, and urethra) (From https://www.cancer.gov/publications/dictionaries/cancer-terms/def/urinary-tract-infection)

Urinary Incontinence: Inability to hold urine in bladder (from https://www.cancer.gov/search/results?swKeyword=urinary+incontinence)

Benign Prostatic Hyperplasia: A benign (not cancer) condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine (from https://www.cancer.gov/search/results?swKeyword=benign+prostatic+hyperplasia)

Urinary Tract Calculi: Crystalline mineral deposits that form in the kidney ( from https://www.aafp.org/afp/2006/0701/p86.html)

Diabetes: Any of several diseases in which the kidneys make a large amount of urine (from https://www.cancer.gov/search/results?swKeyword=diabetes)

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Terminologies for Urinary Assessment

Cherney, 2018, as cited in Ernstmeyer & Christman, 2021
Maddukuri, 2021, as cited in Ernstmeyer & Christman, 2021

Pyuria: at least ten white blood cells in each cubic millimeter of urine in a urine sample; typically indicates infection¹.

In severe infections, pus may be visible in the urine.

Hematuria: blood in the urine. Either visualized or found during microscopic analysis.

Urgency: a sensation of an urgent need to void².

Can cause urge incontinence if the client is not able to reach the bathroom quickly.

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Terminologies for Urinary Assessment

Frequency is the need to urinate several times during the day or at night (nocturia) in normal or less-than-normal volumes.

May be accompanied by a feeling of urgency¹.
Causes: UTI, urinary incontinence, benign prostatic hyperplasia, urinary tract calculi, diabetes, etc.²

Urinary Retention is a condition where the client cannot empty all of the urine from their bladder.

Maddukuri, 2021, as cited in Ernstmeyer & Christman, 2021
Maddukuri, 2021

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Terminologies for Urinary Assessment

Urinary incontinence: Involuntary loss of urine.
Enuresis: Incontinence when sleeping (i.e bed-wetting), normal until 7-8 years of age.
Stress urinary incontinence The involuntary loss of urine with intra-abdominal pressure or physical exertion (e.g., laughing, jumping).

Caused by weak pelvic floor muscles.

Urge urinary incontinence (overactive bladder) is urine leakage caused by the sensation of a strong desire to void,

increased sensitivity to stimulation by the detrusor muscle of bladder or decreased inhibitory control of the central nervous system¹.

Tso, 2018, as cited in Ernstmeyer & Christman, 2021

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Terminologies for Urinary Assessment

Mixed urinary incontinence is a mix of urinary frequency, urgency, and stress incontinence.
Overflow incontinence is leaking of small amounts of urine from bladder that is always full.

Tends to occur in males with enlarged prostates that prevent the complete emptying of the bladder¹.

Functional incontinence occurs in those with normal bladder control but have a problem getting to the toilet because of disorders that make it hard to move quickly or manipulate zippers or buttons.

Dementia also have increased risk for functional incontinence.

National Institute of Aging, 2017, as cited in Ernstmeyer & Christman, 2021

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What Would a Nurse Do?

A 13 year old client, who is 25 kilogram, had urine output of 400 ml in 24 hours. What is this called?

Polyuria
Oliguria
Normal urination
Anuria

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Urinary Tract Infection

Most common type is a bladder infection (cystitis)
Kidney infections (pyelonephritis) are more serious that may cause long-lasting effects on the kidneys¹.
More common in females because urethra is shorter and closer to the rectum.
Risks of UTI:

A previous UTI
Sexual activity
Pregnancy
Age (elderly and children at higher risk)
Structural problems in the urinary tract, such as prostate enlargement¹.

Centers for Disease Control and Prevention, 2019, as cited in Ernstmeyer & Christman, 2021

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Urinary Tract Infection

Symptoms of UTI:

Dysuria
Frequent urination
Urgency with small amounts of urine
Hematuria
Pressure or cramping in the groin or lower abdomen
Confusion or altered mental status in older adult

Symptoms of more serious kidney infection also include:

Fever above 101^oF (38.3^oC)
Shaking chills
Lower back pain or flank pain (i.e., on the sides of the back)
Nausea or vomiting

Centers for Disease Control and Prevention, 2019, as cited in Ernstmeyer & Christman, 2021

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UTI: Nursing Intervention

Assess for sign/symptoms of UTI.
Obtain urine sample before antibiotic is started.
Encourage drinking extra fluids to help flush bacteria from the urinary tract.
Maintain asepsis while performing urinary catheterization to prevent catheter-associated urinary tract infection (CAUTI).

Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter¹.

Centers for Disease Control and Prevention, 2015

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UTI: Nursing Intervention

Provide client education

Stress importance of finishing their antibiotic therapy as prescribed, even if they begin to feel better after a few days.
Prevention strategies for future UTIs:

Urinate after sexual activity.
Stay well-hydrated and urinate regularly.
Take showers instead of baths.
Minimize douching, sprays, or powders in the genital area.
Wiping perineum front to back for females¹.

Centers for Disease Control and Prevention, 2019, as cited in Ernstmeyer & Christman, 2021

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Urinary Incontinence

Inability to control urine.
It is abnormal but a common symptom.
Can seriously affect the physical, psychological, and social well-being of affected individuals of all ages.
Develops in estimated 1 in 5 women.
Many are too embarrassed to discuss the condition with their health care providers.

Some believe it’s a normal part of aging that they have to live with.
Result can be isolation and depression when they limit their activities and social interactions because of embarrassment due to incontinence.

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Urinary Incontinence: Nurse’s Role

Assess for urinary incontinence in a sensitive manner:

Noticing wet garment on client
Health history

Ask ‘Do you have any problems with the leakage or dribbling of urine? Do you ever have problems getting to the bathroom in time?”

Identify the type of incontinence

Encourage client to start a voiding diary to record their urination habits and activities that includes:

When and how much the client urinates
Urinary leakage and activities that causes it
Sudden urges to urinate

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Urinary Incontinence: Nurse’s Role

Note how often the client wakes at night to use the bathroom
Note type and volume of food and beverages and the time of intake
Note medication use, such as diuretics, and the timing of administration
Note any pain or problems experienced before, during, and after urinating (for example, sudden urges, difficulty urinating, dribbling urine, feeling as if the bladder is never empty, weak urine flow)

Use therapeutic communication to encourage client share their feelings.
Check for skin irritation around perineum or urethral area and manage.
Provide client education on performing pelvic floor exercises.

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Urinary Incontinence: Client Education

Teach Timed voiding:

Urinate on a set schedule regardless of urge to void.
Time between bathroom trips is gradually extended to 4 hours between voiding.
Trains brain to be less sensitive to the sensation of the bladder walls expanding as they fill.

Life-style changes:

Drink less coffee, limiting fluid intake before bedtime.
Schedule diuretic in the morning or early afternoon may help.
Lose weight, preventing constipation, and avoiding lifting heavy objects.

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Urinary Incontinence: Client Education

Provide information on protective products that protect skin breakdown and prevent leakage onto clothing.
Refer to appropriate specialist regarding use of:

Biofeedback

Uses sensors to help a client become more aware of signals from the body to regain control over the muscles in their bladder and urethra.

Mechanical devices, such as pessaries, support the urethra and can support vaginal prolapse to prevent or reduce urinary leakage.
Surgical intervention.

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Urinary Retention

Caused by a blockage that partially or fully prevents the flow of urine or the bladder.
Can be acute or chronic.

E.g. Sudden inability to urinate after receiving anesthesia during

surgery, or a gradual inability to completely empty the bladder due to enlargement of the prostate gland in males.

Increases the client’s risk for developing a UTI.
Sign/symptoms range from none to severe pain.
Management may include:

Catheterization to drain the bladder
Bladder training therapy
Medications, or surgery

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Nurse’s Role Urinary Retention

May take post-void residual measurement with a scanner or by inserting straight urinary catheter into bladder after voiding.

Determines how much urine is left in the bladder.
Physician should be notified if post-void residual > 300 ml.

Ensure asepsis during catheterization procedures to prevent infection.
Provide client education about the safe use of prescribed medication for management of retention.

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What Would a Nurse Do?

The client is incontinent, and a condom catheter is placed. The nurse should take which action?

Secure the condom with adhesive tape
Change the condom every 48 hours
Assess the client for skin irritation
Use sterile technique for placement

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Urine Specimen

First void or “morning urine” samples are considered best representative for testing.

More concentrated, provides insight into kidneys concentrating capacities.
Allows for the detection of trace amounts of substances that many not be present in diluted samples.

Other types of urine specimens may need to be collected at other times as per specific purposes.

E.g. randomly, 2-hours postprandial, 24-hour collection.

(Queremel Milani & Jialal, 2021)

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Urine Specimen

For UTI, specimen: Collect before antimicrobial is started¹.

Antimicrobial might affect the the result of urinalysis.

Specimen should be examined within first hour of collection².

Due to the instability of some urinary components (cells, casts, and crystals).

If examination is not possible within first hour of collection, specimen should be stored in the refrigerator at 4^oC².

Will slow down decomposition process.
Not suitable for urinalysis after 24 hours.

Shepherd, 2017
Queremel Milani & Jialal, 2021

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Urine Specimen Collection

Fundamental principle of specimen collection is to obtain it without external contamination¹.

Obtain client’s informed consent prior collection procedure.
Wear gloves and gown as per agency policy.
Select clean specimen container for routine urinalysis and sterile container for urine culture test.

Never touch the inside of the containers.

Ensure asepsis using clean or sterile technique as required.
Label specimen container with client identification information.
Transport the specimen safely as per agency policy.

Queremel Milani & Jialal, 2021
Shepherd, 2017

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Urine Specimen Collection: Non-Invasive Method

Spontaneous voiding into specimen container.
For incontinence, external urine bag/pouch might be placed in perineum or penis.
‘Clean Catch’ technique is applied.

Skin surrounding the urethra should be cleaned with a special towelette before the urine is collected.
Client first voids small amount of urine in toilet, then stops midstream, and voids into specimen container.

15 mL to 30 mL of urine is sufficient for accurate analysis, except for 24-hr collection.

Queremel Milani & Jialal, 2021

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Urine Specimen Collection: Invasive Method

Warranted when client:

Cannot cooperate.
Have urinary incontinence and external urethral ulceration that increases contamination risk.

Urethral catheterization involves inserting urinary catheter through the urethral meatus.

Urine samples is collected from sample port of the catheter tube instead of urine collection bag.

Suprapubic needle aspiration involve inserting needle into bladder through suprepubic area.

Risk for blood contamination, giving false-positive results for protein, red and white cells.

Queremel Milani & Jialal, 2021

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Urine Assessment and Laboratory Test

Urine dip
Urinalysis
Urine Culture
Cystoscopy
Urodynamic flow studies

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Urine Dip

Refers to a treated chemical strip (dipstick) being placed in a urine sample.
Patches on the dipstick will change color to indicate the presence of substances such as white blood cells, protein, or glucose.
Urine is collected with ‘clean catch’ technique.

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Urinalysis

A urinalysis is a laboratory examination of a person's urine
There are three parts to Urinalysis:¹

Physical observation
Chemical examination
Microscopic Examination

Queremel & Jialal, 2021

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Urinalysis: Physical Examination

National Institute of Health, 2019, as cited in Ernstmeyer & Christman, 2021
Queremel & Jialal, 2021

Normal urine color:

Clear, pale to light yellow in color¹.
Some foods and medications might change urine

color² and nurses must be knowledgeable of them.

Odor: Urinoid’², Not foul-smelling.
Appearance:

Normal: Clear or translucent².
Abnormal: Bloody, blood clots, cloudy, epithelial cells².

Volume: 0.5 to 1.5 cc/kg/hour or 600 and 2,000 mL daily in adults.
Specific gravity (USG)/Osmolality (O) indicate the kidney's capacity to dilute or concentrate urine².

Normal: USG = 1.002-1.035

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Urinalysis: Chemical Examination

Queremel & Jialal, 2021

pH: Normal 4.5 to 8 (usually 5.5 to 6.5)

Vital piece of information and provides insight into tubular function.
Helpful for the diagnosis and management of urinary tract infections and crystals/calculi formation.

Protein: Normally present in urine only in trace amounts.

Albuminuria of 30 mg/day to 300 mg/day is an indicator of early renal disease, glomerular injury, and risk of progression of renal disease.

Blood Cells: Normal: Negative (usually) or less than or equal to 5 RBCs per mL (lab-dependent value).

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Urinalysis: Chemical Examination

Glucose should not be present in urine

Its presence may indicate Diabetes mellitus (DM), Cushing syndrome, or other conditions.

Bilirubin-conjugated should not be present in urine

Its presence indicate liver dysfunction, biliary obstruction,etc.

Urobilinogen: Normal: 0.1 mg/dL to 1 mg/dL in random samples or up to 4 mg/daily

Elevation: Hemolysis, liver disease (cirrhosis, hepatitis), sickle cell disease, thalassemia.
Decrease: Antibiotic use, bile duct obstruction.

Queremel & Jialal, 2021

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Urinalysis: Chemical Examination

Ketones bodies should not be present in urine.

Are products of fat metabolism.
Presence may indicate uncontrolled DM, preeclampsia.

Nitrites should not be present in urine.

Its presence indicates a UTI.

Leukocyte Esterase should not be present in urine.

Its presence may indicate inflammation of urinary tract, fever, glomerulonephritis, etc.

Queremel & Jialal, 2021

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Urinalysis: Microscopic Examination

Red blood cells and White blood cells: Normal: 0-5 cells/high-power field,

Higher number may indicate: UTI, inflammation.

Eosinophils should not be present in urine.
Epithelial cells: Less than or equal to 15-20 squamous epithelial cells/high-power field.
Crystals and Casts should not be present in the urine.

Crystals are products of metabolism are found highly concentrated in the urine and can precipitate in the form of crystals.
Casts are a coagulum composed of the trapped contents of tubule lumen and Tamm-Horsfall mucoprotein.

Queremel & Jialal, 2021

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Urine Culture

Identifies the specific microbe causing a urinary tract infection.
Urine sample should be collected in sterile container using ‘Clean catch’ technique.
A culture that is reported as “no growth in 24 or 48 hours” usually indicates that there is no infection.
If a culture is positive, susceptibility testing is performed to guide treatment.

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Cystoscopy

Physician uses cystoscope, a small, thin tube with a camera on the end that is inserted into the urethra and into the bladder.
Biopsy samples can be taken from abnormal tissue through the tube.

A slight pinch may be felt if a biopsy sample is obtained.
Presence of small amount of blood in urine after procedure is normal.
Provider should be notified if bleeding continues after urinating three times, or if other signs of infection are present.

Bladder must remain full until the procedure is completed.
Client should be encouraged to drink 4 to 6 glasses of water per day, as appropriate for their medical status.

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Urodynamic Flow Test

Any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine.
Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely.
Urodynamic tests can also show whether the bladder is having involuntary contractions that cause urine leakage.

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What Would a Nurse Do?

The client states that she "loses urine" every time she laughs or coughs. The nurse teaches the client measures to regain urinary control.

Which of the following client’s statement warranty the need for further teaching?

"I will perform my Kegel exercises every day."
"I joined weight watchers."
"I drink two glasses of wine with dinner."
"I have tried urinating every 3 hours."

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Red Flags

Fever, chills, back pain, body ache, nausea and vomiting.
Hematuria, oliguria, anuria, polyuria.
Urine is cloudy, foul smelling.

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Cultural Consideration

Be aware of cultural differences in comfort level of client in communicating problems relating to urination as it is associated with private body parts.
Use culture sensitive communication skills to make client feel comfortable to talk about issues with urination.

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References:

Centers for Disease Control and Prevention (2015). Catheter-associated Urinary Tract Infections (CAUTI). Retrieved from: https://www.cdc.gov/hai/ca_uti/uti.html

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0. Retrieved from: https://wtcs.pressbooks.pub/nursingfundamentals/open/download?type=pdf

Maddukuri, G. (2021). Urinary frequency. MSD Professional Version. Retrieved from: https://www.msdmanuals.com/professional/genitourinary-disorders/symptoms-of-genitourinary-disorders/urinary-frequency

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References:

Michels, T.C. & Sands, J.E. (2015). Dysuria: Evaluation and Differential Diagnosis in Adults. American Family Physician, 92(9):778-788. Retrieved from: https://www.aafp.org/afp/2015/1101/p778.html

Shepherd, E. (2017). Specimen collection 1: general principles and procedure for obtaining a midstream urine specimen. Nursing Times [online]; 113: 7, 45-47. Retrieved from: https://www.nursingtimes.net/clinical-archive/assessment-skills/specimen-collection-1-general-principles-and-procedure-for-obtaining-a-midstream-urine-specimen-12-06-2017/

Queremel Milani, D.A., & Jialal, I. (2021). Urinalysis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK557685/

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