Alterations in Urinary Elimination

U 230 Adult Health 1

ALTERATIONS IN URINARY
ELIMINATION
1

Class Outline Care of the Patient:

Undergoing diagnostic testing
With a lower urinary tract infection
With urinary incontinence
With urinary retention
With urolithiasis
Experiencing urinary diversions
Undergoing prostate surgery
2
***Tables & Charts***

Think about:
Whos at risk?
Why & So What?
Preventive interventions
Assmt/Planning/Implementation/
Evaluation
Study Tables & Charts
3
Chapter 53
Assessment of Kidney and
Urinary Function
Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Kidney and Urinary Systems

Regulates fluid and electrolytes, removing wastes and
providing hormones involved in red blood cell production,
bone metabolism, and control of blood pressure
Structures
Kidneys
Ureters
Bladder
Urethra
Kidneys, Ureters, and Bladder
Assessment (pgs.1514-1517)
Requires excellent communication skills
Risk factors
Chief complaint/Effect on quality of life
Symptoms
Pain (Table 53-2)
Changes in voiding (Table 53-3)
GI symptoms
Gero considerations (see p. 1513)
7
Diagnostic Studies (pgs 1518-1524)

Urinalysis and urine
culture
Renal function tests:
refer to Table 53-5
Ultrasonography
CT and MRI
Nuclear scans
Endoscopic procedures
Biopsies
IV urography
Retrograde pyelography
Cystography
Renal angiography
Refer to Chart 53-4
Urinalysis
Whats normal/what isnt/what
does it mean? - and then
what?
Color (Table 53-4)
Clarity & odor
Specific gravity (normal range 1.010-
1.025)
pH (nl @ 6)
Protein, glucose, ketone bodies, nitrites
Other Urine Tests

Urine for culture and sensitivity
Composite urine collections (24 hr)
Creatinine clearancebest
indication of overall kidney

function (approximation of GFR)
Urine osmolality (300-900
mOsm/kg/24h)
Lab Assessment of Renal

Function
Serum creatinine (will not increase

unless 50% of kidney function is lost)
BUN (can elevate from high protein

diet, tissue damage, infection, stress,
dehydration)
Serum creatinine more reliable
SC = 0.6-1.2 mg/dl
BUN = 7-18mg/dl
11
Risks and Nursing Interventions in

Evaluations of Urinary System
All tests consider general principles
What position is needed?

Patient Education
Informed Consent if risk
Before and after care
Common nursing diagnoses/etiology: (Chart 53-4)
Deficient knowledge
Acute pain
Fear and anxiety
Special considerations
e.g. urodynamic testing, imaging, cystoscopy, biopsy
12
Intravenous Urography
IVP Study
IVP= Intravenous Pyelography
What used for- assess gross kidney size or
obstruction
IV dye given then X-rays taken
Requires bowel prep so bowel contents will not
block picture
Normal to feel hot, flushed feeling when dye
injected
Not used as often secondary to multiple risks and
newer tests
13
IVP
Risks and Nursing Interventions
Dye Studies Risks: Allergy, Nephrotoxic
Pre: assess iodine, contrast, shellfish
allergy, NPO to concentrate dye
Post: Monitor fever, wheeze, rash,
nausea, vomiting, rehydrate, monitor
renal function and I/O, serum Creat.,
may give acetylcysteine or IV sodium
bicarb to prevent renal damage
14
Case
George Wright, 63 years of
age, is admitted in same day

surgery for a renal angiogram
for the diagnosis of renal
artery stenosis.
15
Questions
What patient education should
the nurse provide to the patient?

What preparation should the
nurse provide for the patient who

is going for a renal angiogram?
16
Renal Arteriography:
Catheter is inserted in femoral
artery at groin, to renal artery,

dye injected, x-ray pictures
Used to monitor for vascular
problems
17
Renal Arteriography Risks and

Nursing Interventions
Risk: Bleeding: Prior to procedure monitor
PT/PTT,discontinue anticoagulants
Post: Pressure to catheter insertion site

Manual, ice and sand bag X 15 minutes
Bed-rest- 6 hours, then stand to void or
bedside commode x24hrs

Vital Sx q 15 minx4 etc,
H+H
Monitor for hematoma
18
Arteriography Risks and

Interventions:
Risk: Embolus
Pre: Assess pulses, pedal pulses
Post: monitor for occlusion of femoral artery:
6 Ps, monitor distal pulses, notify MD
Risk: Infection : insertion of catheter / sterile
procedure
Post- temp q4hx48 to 72 h, monitor for
chills, malaise, WBC
Risk: renal failure secondary to dye
19
Oscopy ( cystoscopy,
ureteroscopy)
Insertion of a scope into cavity to visualize or
treat.
Used for bladder wall problems or
obstructions
Interventions
NPO, laxative or fleets to remove stool from
the lower colon

Pain: Post: General or local anesthesia
Monitoring , mild discomfort
20
Cystoscopic Examination
Oscopy ( cystoscopy,
ureteroscopy
Infection-sterile procedure
Post- temp q4h -72h, monitor etc
Local trauma- assess bleeding- pink
tinged urine is normal, gross

hematuria is not, assess function
(leaking, retention)
If catheter in place- clots can obstruct
it. May need irrigation

22
Biopsy- Insert needle into kidney

Used for unexplained renal problems or
renal CA dx
Pre- assess ability to lie +breathe in
prone, NPO
Pre- patient is sedated
Prone position 30-45 min
hold breath on request 15-30 seconds
Infection- sterile procedure -- same as
above
23
Biopsy Risks
Post: Bleed Risk- BR, supine with back
roll( putting pressure on puncture site). At

least 6 hrs, then limited BRP if no bleeding
Can elevate HOB if back roll stays
monitor: VS, H+H, assess bleeding, pink
tinge ok, - no blood
monitor for hemorrhaging- pain, decr BP
Post - hematuria
Post- pain
Post- Infection- sterile procedure - same as
above
24
Chapter 55
Management of Patients With
Urinary Disorders
Why does this patient need a NURSE?
26
Case
Sue Meade, 22 years of age,

presents to the clinic with
complaints of burning, pain,
and urgency when urinating.
The patient has a fever of
100F. The urine is strong in
odor and cloudy with
sediments.
27
Questions
a. What questions should the nurse
ask during the assessment to gain
more information about the
possible causes of the urinary
tract infection?
b. What patient education should
be provided?
28
Urinary Tract Infections

Most common reason
health care
Common site of acquired
infection
Lower UTI
Upper UTI
Pyelonephritis: acute
and chronic
Interstitial nephritis
Renal abscess and
perirenal abscess
Cystitis
Prostatitis
Urethritis
Factors Contributing to UTI

Function of glycosaminoglycan (GAG)
Urethrovesical reflux
Uretherovesical reflux
Uropathogenic bacteria
Shorter urethra in women
Risk factors
Risk Factors for UTI (see Chart

55-2)
Incomplete bladder emptying
Obstruction
Immunosuppression
Instrumentation
Inflammation of urethra
Contributing conditions
e.g. DM, neurologic disorders
31
Bladder Infection: Long-Term Catheterization
Nursing Process: The Care of the Patient

With a UTIAssessment
Pain, burning upon urination, frequency, nocturia,
incontinence, hematuria
About half are asymptomatic
Association of symptoms with sexual intercourse,
contraceptive practices, and personal hygiene
Gerontologic considerations
Assessment of urine, urinalysis, and urine cultures
Other diagnostic tests

With a UTIDiagnosis
Acute pain
Deficient knowledge
Predisposing factors: infection
Recurrence
Detection
Prevention
Pharmacologic therapy
Collaborative Problems and Potential

Complications
Sepsis
Renal failure

With a UTIPlanning
Major goals may include relief of pain and discomfort,
increased knowledge of preventive measures and
treatment modalities, and absence of complications.
Interventions
Personal hygiene: wipe front to back
Medications as prescribed: antibiotics, analgesics, and
antispasmodics
Application of heat to the perineum to relieve pain and
spasm
Increased fluid intake
Avoidance of urinary tract irritants such as coffee, tea,
citrus, spices, cola, and alcohol
Frequent voiding
Patient education
Question
Is the following statement true or false?
Older adult patients often lack the typical symptoms
of UTI and sepsis.
Answer
True
Older adult patients often lack the typical symptoms
of UTI and sepsis.
Urinary Incontinence
An underdiagnosed and underreported problem that can
have significant impact on the quality of life and decrease
independence, which may lead to compromise of the
upper urinary system
Urinary incontinence is not a normal consequence of
aging
Risk factors: refer to chart 55-6
Urinary Incontinence/Assessment
History and observation
Physical
Psychosocial
UI in Hospitalized Older Adults
More than 25 million
35% admitted to hospital
What are risk factors and complications?
See consultgerirn.org reading
41
Types of Urinary Incontinence

Stress
Urge
Reflex
Overflow
Functional
Iatrogenic
Mixed incontinence
Urinary Incontinence/ stress

Nursing DX- stress incontinence
Leakage of <50ml with sudden increase in
abd pressure ( cough, sneeze, laugh, lift)

Mostly female
Cause: weakness of urethral and
surrounding pelvic muscles, childbirth

trauma, aging. Men after prostate surgery
43
Stress Inc/ Management

Behavioral Therapy:
Pelvic muscle exercises (PME) - Chart 55-8
10-30 reps; 2-3x/day; 6 weeks
Voiding diary, biofeedback, PT
Weight loss if appropriate
Skin care
Meds as adjunct
anticholinergics, tricyclic antidepressants, (estrogen?)
Surgical management (see text pg- 1584)
44
Urge Incontinence
Unable to suppress the urge to void
Involuntary
Causes: Neurogenic bladder (spastic and flaccid
bladder), uninhibited detrusor contraction
Behavioral Therapy (Chart 55-8)

Timed voiding, habit retraining, bladder
retraining
PME
Urge inhibition strategies
Meds as adjunct
Anticholinergics inhibit bladder contraction
45
Incontinence contd..
Functional Incontinence
Results from non-urologic cause, from some physical, mental,
or environmental factor that prevents pts from reaching BR.
Treat underlying cause
Iatrogenic Incontinence
Involuntary loss of urine due to extrinsic medical factors

Medications (Example- Alpha adrenergic agents)
Incontinence resolves as soon as is discontinued
Mixed Urinary Incontinence
Involuntary leakage associated with urgency, exertion, effort,

sneezing, or coughing
46
Total Incontinence
neurologic injury- s2-s4,
degenerative diseases , fistula

bladder to vagina, Cystectomy
Management- pads etc, prevent skin
breakdown, UTIs
Intravaginal pessary
Intravaginal balloon
Penile Clamp/ Condom cath
47
Patient Education
Urinary incontinence is not inevitable and is treatable
Management takes time (provide encouragement and
support)
Develop and use a voiding log or diary
Behavioral interventions
Medication education related to pharmacologic therapy
Strategies for promoting continence
Urinary Retention
Inability of the bladder to empty completely
Residual urine: amount of urine left in the bladder after
voiding
Causes include age (50100 mL in adults older than age
60 years caused by decreased detrusor muscle activity),
diabetes, prostate enlargement, pregnancy, neurologic
disorders, medications
Nursing measures to promote voiding: refer to Chart 559
Retention
Definition- No normal urge to void
at 250-450ml
Inability to initiate voiding or
empty bladder completely
Symptoms: Distension d/t residual
urine
Can lead to overflow incontinence
or UTIs
50
Retention
Causes: Medical conditions, post-op,
post-delivery, meds, obstruction,

neuro damage
Interventions- Treat cause if possible
Catheterization/ Intermittent/
Residual
Whats normal PVR?
51
Retention
Bladder Training
Crede only if no outlet
obstruction
Valsalva
Double voiding technique
52
Urolithiasis and Nephrolithiasis

Calculi (stones) in the urinary tract or kidney
Pathophysiology
Causes: may be unknown
Depend on location and presence of obstruction or
infection
Pain and hematuria
Diagnosis: radiography, blood chemistries, and stone
analysis; strain all urine and save stones
Case study
John Lyons has undergone treatment for renal
stones three times in the last year. Today he calls

this primary health care provider with complaints of
acute, excruciating, colicky, pain that radiates down
the thigh toward the genitalia. The pain started last
night, and has become progressively more severe.
He also complains of the urge to void but has little
urine output, and it is blood tinged. Due to the pain,
he has not taken any fluids or food in 24 hours. Mr.
Lyons undergoes lithotripsy, and analysis of stone
fragments to reveal calcium stones.
54
Questions
a. Mr. Lyons symptoms are most indicative of stones
in what area of the renal system?
Mr. Lyons has the following orders:
Morphine sulfate 2 mg IVP every 2 hours as
needed for severe pain

Ibuprofen 600 mg every 6 hours
Normal saline at 200 mL/hr
b. What are the rationales for the above orders?
c. Based on the calcium composition of the stone,
what dietary teaching should the nurse include in
Mr. Lyons plan of care? 55
Patient Education
Signs and symptoms to report
Follow-up care
Urine pH monitoring
Measures to prevent recurrent stones
Importance of fluid intake
Dietary education
Medication education as needed
Genitourinary Trauma
Gunshot wounds = 95% of ureteral injuries
Pelvic fractures, blunt trauma
S/S classic triad: blood visible at the meatus, inability to
void, distended bladder
Urinary Cancers
Bladder cancer more common after age 55 years
Men four times as often as women; 15,000 deaths
annually
Smoking increases risk 50%; refer to Chart 55-13
S/S: visible painless hematuria; pelvic or back pain may
indicate metastasis
Diagnosis: cystoscopy, CT, ultrasonography, biopsy
Treatment: surgery, fulguration, BCG regimen
Urinary Diversion
Reasons: bladder cancer or other pelvic malignancies,
birth defects, trauma, strictures, neurogenic bladder,
chronic infection or intractable cystitis; used as a last
resort for incontinence
Cutaneous urinary diversion: ileal conduit, cutaneous
ureterostomy, vesicostomy, nephrostomy
Continent urinary diversion: Indiana pouch, Kock pouch,
uretherosigmoidostomy
Nursing Diagnosis: Preoperative

Anxiety
Imbalanced nutrition
Deficient knowledge
Nursing Diagnosis: Postoperative

Risk for impaired skin integrity
Acute pain
Disturbed body image
Potential for sexual dysfunction
Deficient knowledge
Chapter 59
Assessment and Management of
Problems Related to Male
Reproductive Processes
Assessment
Urinary function and symptoms
Sexual function and manifestations of sexual dysfunction
Symptoms related to urinary obstruction
Increased urinary frequency
Decreased force of stream
Double or triple voiding
Nocturia, dysuria, hematuria, hematospermia
Medications, drug, and alcohol use
Presence of conditions that may affect sexual function
(diabetes, cardiac disease, multiple sclerosis)
Conditions of the Prostate

Prostatitis: inflammation caused by an infectious agent
Treatment includes appropriate anti-infective agents and
measures to alleviate pain and spasm
Benign prostatic hyperplasia (BPH; enlarged prostate)
Effects half of men older than age 50 years and 80% of

men older than age 80 years
Manifestations are those of urinary obstruction, urinary

retention, and urinary tract infections
Treatment
Pharmacologic: alpha-adrenergic blockers, alphaadrenergic antagonists, antiandrogen agents
Catheterization if unable to void
Prostate surgery
Prostate Cancer
Second most common cancer and the second most common
cause of cancer death in men
Risk factors include increasing age, familial predisposition, and
African American race
Manifestations
Early disease has few or no symptoms
Symptoms of urinary obstruction, blood in urine or semen,

painful ejaculation
Symptoms of metastasis may be the first manifestations
Early diagnosis is vital; health screening

Treatment may include prostatectomy, radiation therapy,
hormonal therapy, or chemotherapy

Undergoing ProstatectomyAssessment
Assess how the underlying disorder (BPH or prostate
cancer) has affected the patients lifestyle
Urinary and sexual function
Health history
Nutritional status
Activity level and abilities

Undergoing Prostatectomy Diagnoses
Anxiety
Acute pain preoperatively
Acute pain postoperatively
Risk for imbalanced fluid volume postoperatively
Deficient knowledge
Collaborative Problems and Potential

Complications
Hemorrhage and shock
Infection
Venous thromboembolism
Catheter obstruction
Complications with catheter removal
Urinary incontinence
Sexual dysfunction

Undergoing ProstatectomyPlanning
Major goals before surgery include adequate preparation
and reduction of anxiety and pain.
Major goals after surgery include maintenance of fluid
volume balance, relief of pain and discomfort, ability to
perform self-care activities, and absence of
complications.
Relief of Pain
Monitor urinary drainage and keep catheter patent
Assessment of pain
Bladder spasms cause feelings of pressure and
fullness, urgency to void, and bleeding from the
urethra around the catheter.
Medication and warm compresses or sitz baths to relieve
spasms
Administer analgesics and antispasmodics as needed
Encourage patient to walk but to avoid sitting for
prolonged periods.
Prevent constipation
Irrigate catheter as prescribed
Three-Way System for Bladder Irrigation
Interventions
Reduction of anxiety
Be sensitive to potentially embarrassing and
culturally charged issues
Establish a professional, trusting relationship
Provide privacy
Allow patient to verbalize concerns
Provide and reinforce information
Provide patient education, including explanations of
anatomy and function, diagnostic tests and surgery, and
the surgical experience.
Rehabilitation and Home Care

Patient and family education for home care, including care of
urinary drainage devices and recognition and prevention of
complications
Regain bladder continence
Information that regaining control is a gradual process

(dribbling may continue for up to 1 year depending on
type of surgery)
Perineal exercises
Avoidance of straining, heavy lifting, long car trips (68 weeks)

Diet: encourage fluids and avoid coffee, alcohol, and spicy
foods
Assessment and referral of sexual issues
Case Study
Joe Smith, a 55-year-old patient, is admitted to
the surgical unit after robotic-assisted

laparoscopic radical prostatectomy with nerve
sparring for early stage cancerous tumor
confined to the prostate. The client has six
small incisions in the abdomen with small 44
dressings with clear dressing dry and intact.
The client has a JP drain in place with clear, redcolored drainage with 50 mL present and an
indwelling urinary catheter draining clear, redcolored urine. The surgeon ordered ketorolac
(Toradol) for pain management and belladonna
74
and opiate (B&O) suppository
every 8 hours, as
Questions
What nursing care should be provided to the
patient in the immediate postoperative period?

For what potential complications should the nurse
observe, and what actions should the nurse take

if the complication develops?
The surgeon removes the JP drain the next day
and discharges the patient with the indwelling

urinary catheter to a leg bag. What discharge
instructions should the nurse provide the patient?
What follow-up care is anticipated for him?
75
What knowledge is needed?

Nursing is the protection, promotion, and
optimization of health and abilities,
prevention of illness and injury, alleviation
of suffering through the diagnosis and
treatment of human response, and
advocacy in the care of individuals,
families,
communities, and populations.
American Nurses' Association. (2003). Nursings social policy statement, 2nd edition.
Silver Spring, MD: Nursesbooks.org

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U 230 Adult Health 1

Class Outline Care of the Patient:

***Tables & Charts***

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kidney and Urinary Systems

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kidneys, Ureters, and Bladder

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagnostic Studies (pgs 1518-1524)

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Other Urine Tests

indication of overall kidney

Lab Assessment of Renal

Serum creatinine (will not increase

BUN (can elevate from high protein

Serum creatinine more reliable

Risks and Nursing Interventions in

What position is needed?

age, is admitted in same day

the nurse provide to the patient?

nurse provide for the patient who

artery at groin, to renal artery,

Renal Arteriography Risks and

Post: Pressure to catheter insertion site

bedside commode x24hrs

Arteriography Risks and

6 Ps, monitor distal pulses, notify MD

Risk: Infection : insertion of catheter / sterile

Risk: renal failure secondary to dye

the lower colon

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

tinged urine is normal, gross

If catheter in place- clots can obstruct

it. May need irrigation

Biopsy- Insert needle into kidney

Pre- assess ability to lie +breathe in

roll( putting pressure on puncture site). At

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Why does this patient need a NURSE?

Sue Meade, 22 years of age,

Urinary Tract Infections

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Contributing to UTI

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk Factors for UTI (see Chart

Bladder Infection: Long-Term Catheterization

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Problems and Potential

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Urinary Incontinence

Tables & Charts