Assessment and management of urinary elimination - meeting special need: nursing foundation: meeting special need of patient

1. Assessment and management of
urinary elimination
By,
Ms. Ekta S Patel
Assistant Professor

2. Normal Urinary Function
× Normal urine output is 60mL/hr or
1500mL/day; should remain 30 mL/hr to
ensure continued normal kidney function
× Urine normally consists of 96% water

3. × Solutes found in urine include:
× Organic solutes: urea, ammonia, uric
acid and creatinine
× Inorganic solutes: sodium,
potassium, chloride, sulfate,
magnesium & phosphorus

4. × Factors influencing
urinary elimination

5. × Lifestyle
× Fluid and food intake
× Environment
× Psychological factor
× Medication
× Muscle tone and activity
× Pathological conditions
× Surgical and memdical procedure

6. × Common
Assessment
Findings

7. Urgency –
× strong desire to void my be
caused by inflammations or
infections in the bladder or
urethra

8. Dysuria –
× painful or difficult voiding

9. Frequency –
× voiding that occurs more
than usual when compared
with the person’s regular
pattern or the generally
accepted norm of voiding
once every 3 to 6 hours

10. Hesitancy –
× undue delay and difficulty in
initiating voiding

11. Polyuria –
× a large volume of urine or output voided
at any given time

12. Oliguria –
× a small volume of urine or
output between 100 to 500
mL/24 hr

13. Nocturia –
× excessive urination at night interrupting
sleep

14. Hematuria
× RBCs in the urine

15. Urinary retention

16. × Incomplete emptying of the
bladder.

17. × Urinary retention, also known as
ischuria, is the body’s failure to
effectively and completely empty
the bladder.

18. Causes:
× Decompensation of detrusor
musculature
× Enlarged prostate
× General anesthesia, regional
anesthesia
× High urethral pressures caused by
disease, injury, edema, and
hematoma

19. × Inability of bladder to contract
adequately
× Inadequate intake
× Infection
× Mechanical obstruction
× Pain, fear of pain
× Sensory/motor impairment, nerve
paralysis
× Surgical manipulation
× Urethral blockage

20. Sign and symptoms
× Abdominal discomfort
× Bladder distention
× Decreased (less than 30 ml/hr) or absent
urinary output for 2 consecutive hours
× Frequency
× Hesitancy

21. × Inability to empty bladder
completely
× Incontinence
× Residual urine
× Sensation of bladder fullness
× Urgency

22. Treatment:
× Urinary cauterization

23. × Suprapubic catheter

24. Nursing Assessment
× Ascertain quantity, frequency, and
character of urine, such as color, odor, and
specific gravity.
× Review previous patterns of voiding.
× Allow patient to keep a record of the
amount and time of each voiding. Take
down decreased urinary output. Determine
specific gravity as ordered

25. × Assess vital signs. Check for
changes in mentation,
hypertension, and peripheral or
dependent edema. Weigh daily.
Maintain precise I&O record.
× Monitor time intervals between
voiding and document the quantity
voided.

26. × Ask patient concerning stress
incontinence when moving,
sneezing, coughing, laughing, and
lifting objects.
× Palpate and percuss suprapubic
area. Examine verbalization of
discomfort, pain, fullness, and
difficulty of voiding.

27. × If an indwelling catheter is in
place, assess for patency and
kinking.

28. Nursing Intervention
× Promote fluids, if not
contraindicated.
× Cranberry juice keeps the acidity
of urine. This aids in preventing
infection.

29. × Place the patient in an upright
position to facilitate successful
voiding.
× Provide privacy: Privacy aids in
the relaxation of urinary
sphincters.
× Encourage the patient to void at
least every 4 hours.

30. × Allow the patient to listen to
the sound of running water, or dip
hands in warm water/pour
lukewarm water over perineum.

31. × Offer fluids before voiding.:
Sufficient urine volume is
necessary to stimulate the voiding
reflex.

32. × Perform Credé’s maneuver:
× Credé’s method (pressing down
over the bladder with the hands)
enhances urinary bladder
pressure, and this consequently
induces relaxation of sphincter to
allow voiding.

33. × Secure the catheter of male
patient to the abdomen and thigh
for female.
× Discuss the importance of
adequate fluid intake.

34. × Inform the patient and significant
other to observe the different signs
and symptoms of bladder
distention like reduced or lack of
urine, urgency, hesitancy,
frequency, distention of lower
abdomen, or discomfort.

35. × Teach the patient to achieve an
upright position on the toilet in
possible.

36. × Suggest sitz bath as ordered:
× A sitz bath supports muscle
relaxation, reduces edema, and
may improve voiding attempt.

37. Urinary incontinence

38. Introduction:
× Urinary incontinence (UI) is any
involuntary leakage of urine.
× Urinary incontinence almost always
results from an underlying treatable
medical condition.

39. Causes
× Polyuria (excessive urine production)
× Caffeine or cola beverages also stimulate
the bladder.
× Enlarged prostate
× Disorders like multiple sclerosis, spina
bifida, Parkinson’s disease, strokes and
spinal cord injury can all interfere with nerve
function of the bladder.

40. Types

41. Stress incontinence
× , also known as effort incontinence, is
due essentially to insufficient strength of
the pelvic floor muscles.

42. Urge incontinence
× is involuntary loss of urine occurring for
no apparent reason while suddenly
feeling the need or urge to urinate.
× Mixed incontinence is not uncommon in
the elderly female population and can
sometimes be complicated by urinary
retention, which makes it a treatment
challenge requiring staged multimodal
treatment.

43. Overflow incontinence:
× Sometimes people find that they cannot
stop their bladders from constantly
dribbling or continuing to dribble for some
time after they have passed urine.
× It is as if their bladders were constantly
overflowing, hence the general name
overflow incontinence.

44. Mixed incontinence
× Is common in the elderly female
population and can sometimes be
complicated by urinary retention, which
makes it a treatment challenge requiring
staged multimodal treatment.

45. Structural incontinence:
× Rarely, structural problems can cause
incontinence, usually diagnosed in
childhood (for example, an ectopic
ureter).

46. Functional incontinence
× occurs when a person recognizes the
need to urinate but cannot make it to the
bathroom. The urine loss may be large.
Causes of functional incontinence include
confusion, dementia, poor eyesight, poor
mobility, poor dexterity,

47. Bedwetting
× Bedwetting is episodic UI while asleep. It
is normal in young children.

48. Transient incontinence
× Transient incontinence is a temporary
version of incontinence.
× It can be triggered by medications,
adrenal insufficiency, mental impairment,
restricted mobility, and stool impaction
(severe constipation), which can push
against the urinary tract and obstruct
outflow.

49. Giggle incontinence
× Giggle incontinence is an involuntary
response to laughter. It usually affects
children.

50. Assessment
× Assessment for urinary incontinence
includes the number of times and
frequency of micturation, characteristics
of urine.
× For patients who are using diapers or
incontinent pads, it should be weigh to
measure the amount of urine.

51. × For patients with indwelling catheter, hourly
measurement is a must to calculate
properly.
× history taking, physical examination,
voiding diary, urinalysis and culture, post-
void residual urine volume (ultrasound or
catheterization), urodynamic testing, pelvic
musculature examination and cough stress
test are the important data to evaluate
urinary incontinence.

52. Implementation

53. 1. Promoting urinary continence:
× Initiate bladder training by providing
schedule with specified time for the
patient to void.
× To optimize the likelihood of voiding as
scheduled, measured amounts of fluids
may be administered about 30 minutes
before voiding attempts.

54. × Fluid intake restriction to decrease the
frequency of urination is not advisable.
Sufficient fluid intake (2000 to 3000
mL/day according to patient needs) must
be ensured to maintain hydration.
× Voiding and episodes of incontinence are
recorded.

55. × Other measures can be helpful to
promote voluntary urination are,
suprapubic tapping or stroking of the
inner thigh may produce voiding by
stimulating the voiding reflex arc.
× Listening to running water or perineal
wash with lukewarm water will also help.

56. 2. Managing patient with altered thought process:
× Interventions are difficult if managing
patients with altered thought process,
catheter as ordered is the last sort for
urinary incontinence,
× strict care is encouraged to prevent
occurrence of infection secondary to
urinary catheterization.

57. × The caregiver must be taught how to
provide daily hygiene, including skin
inspection and catheter care.
× Instruction on emptying the urine bag
must also be provided.
× Diapers and incontinent pads can be an
option but meticulous perineal hygiene is
necessary to prevent complications such
as skin problems and bed sores.

58. 3. Promoting hygiene, skin care and preventing infection:
× Skin care and perineal care should be
done every after voiding using non-
allergenic soap with lukewarm water.
× Always pat dry the perineal area.

59. 4. Provision of comfort:
× When incontinence pads are used, they
should wick moisture away from the body
to minimize contact of moisture and
excreta with the skin. Wet incontinence
pads must be changed promptly, the skin
cleansed, and a moisture barrier applied
to protect the skin.

60. 5. Promoting role performance, promoting body image and
relieving anxiety and stress:
× Privacy should be provided during voiding
efforts.
× Promote positive feedback and optimistic
attitude to reinforce patient’s ego and
esteem.
× Periods of continence and successful
voidings are positively reinforced.

61. 6. Maintaining hydration:
× Monitoring intake and output is necessary
to assess hydration.
× Signs and symptoms of good hydration
and dehydration should be assessed and
monitored every shift.

62. 7. Promoting sleep and rest:
× Fluid intake should be consumed before
evening to minimize the need to void
frequently during the night.