L
EARNING
O
UTCOME
1
Describe the process of urination, from urine formation through micturition.
Concepts for Lecture
1. Urinary elimination depends on effective functioning of the upper
2. Urine is formed in the nephron, the functional unit of the kidney.
Each nephron has a glomerulus, a tuft of capillaries surrounded by
Bowman’s capsule. Fluids and solutes readily move across the endo-
3.
The normal process of urination is stimulated when sufficient urine
collects in the bladder, stimulating special stretch receptors in the blad-
L
EARNING
O
UTCOME
2
Identify factors that influence urinary elimination.
Concepts for Lecture
1. Numerous factors affect the volume and characteristics of the urine
produced and the manner in which it is secreted, such as develop-
between the first and second year; urine is concentrated and urine
becomes amber color; between 18 and 24 months the child is able to
recognize bladder fullness and hold beyond the urge to void; be-
C
HAPTER
48
URINARY ELIMINATION
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Ask the students to review their anatomy and
physiology textbooks and notes on urinary
elimination.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Assign students to select one factor that may
affect the volume and characteristics of urine and
to investigate current research information on the
topic.
• Divide the students into groups and assign each
an age group. Have the students develop an
educational guide for the developmental issues,
• Have the students review the history, physical
examination, medication administration
record (MAR), and care plan of their assigned
clients for factors affecting volume and char-
30% of nephrons are lost by age 80; renal blood flow decreases be-
cause of vascular changes and decreased cardiac output; bladder tone
diminishes, leading to increased frequency and nocturia; decreased
Some psychosocial factors influencing urinary elimination
include privacy, normal position, sufficient time, occasional sound
of running water, change in accustomed conditions, and voluntary
Retention catheters that have been in place for a long period of
time may create poor bladder tone, and poor tone of the pelvic mus-
cles contributes to changes in the ability to store urine and empty the
bladder.
Some pathological conditions affect the formation and excretion
L
EARNING
O
UTCOME
3
Identify common causes of selected urinary problems.
Concepts for Lecture
1. Polyuria refers to the production of abnormally large amounts of
urine. It is associated with ingestion of fluids containing caffeine or
alcohol, prescribed diuretics, presence of thirst, dehydration, weight
loss, and a history of diabetes mellitus, diabetes insipidus, or kidney
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Review common pathologic conditions contrib-
uting to urinary problems and related nursing in-
terventions.
• Discuss incontinence (types and causes) and
have the students investigate interventions to as-
sist clients to cope with this problem.
Frequency (voiding at frequent intervals) and nocturia (voiding
two or more times a night) are associated with pregnancy, increase in
fluid intake, and urinary tract infection.
Urgency, the sudden strong desire to void, is associated with the
presence of psychological stress and urinary tract infections.
Retention, bladder overdistention due to inability to empty the
bladder, is associated with distended bladder on palpation and per-
cussion; signs and symptoms such as pubic discomfort, restlessness,
L
EARNING
O
UTCOME
4
Describe nursing assessment of urinary function, including subjective and
objective data.
Concepts for Lecture
1. A complete assessment of a client’s urinary function includes the
2. The nursing history should include the client’s normal voiding
patterns and frequency, appearance of the urine and any recent
3. The physical assessment usually involves percussion of the kidneys
to detect areas of tenderness; palpation and percussion of the bladder
are also performed. If the client’s history or current problems indi-
4. For information on the assessment of urine, see Learning Outcome 5.
To measure urinary output and residual urine, the nurse assesses
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Review the common laboratory tests performed
to diagnose urinary alterations and related nurs-
ing responsibilities.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
5.
The blood levels of urea and creatinine are routinely used to evaluate
renal function. Urea is the end product of protein metabolism and is
L
EARNING
O
UTCOME
5
Identify normal and abnormal characteristics and constituents of urine.
Concepts for Lecture
1. Normal urine consists of 96% water and 4% solutes. Organic solutes
2. Normal characteristics of urine include volume of 1,200–1,500
4.5 to 8; and specific gravity between 1.010 and 1.025.
Abnormal characteristics of urine include volume of less than
L
EARNING
O
UTCOME
6
Develop nursing diagnoses, desired outcomes, and interventions related to
urinary elimination.
Concepts for Lecture
1. NANDA includes one general diagnostic label for urinary elimina-
tion problems: Impaired Urinary Elimination. NANDA also includes
2. Problems of urinary elimination also may become the etiology for
3. The desired outcomes established will vary according to the diagno-
sis and defining characteristics. Examples of overall general goals
may include the following: maintain or restore a normal voiding pat-
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss the appropriate performance of
“dipstick” urine testing.
• Discuss the significance of each of the organic
solutes found in normal and abnormal urine.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Compare and contrast NANDA diagnoses related
to urinary incontinence based on definition,
defining characteristics, and etiology.
• Discuss interventions the nurse may use to assist
clients to perform toileting activities.
who have nursing diagnoses related to urinary
incontinence. Ask the students to compare and
4. Appropriate preventive and corrective nursing interventions that
relate to these must be specified. Specific nursing activities associat-
ed with each of these interventions can be selected to meet the
client’s individual needs.
L
EARNING
O
UTCOME
7
Describe nursing interventions to maintain normal urinary elimination, pre-
vent urinary tract infection, and manage urinary incontinence.
Concepts for Lecture
1. Most interventions to maintain normal urinary elimination are
L
EARNING
O
UTCOME
8
Delineate ways to prevent urinary infection.
Concepts for Lecture
1. Gastrointestinal bacteria can colonize the perineal area and move
into the urethra, especially when there is urethral trauma, irritation,
or manipulation. Women are at particular risk.
The following guidelines are useful to prevent urinary infection:
• Drink eight 8-ounce glasses of water per day.
• Practice frequent voiding (every 2 to 4 hours).
• Avoid use of harsh soaps, bubble bath, powder, or sprays in the
L
EARNING
O
UTCOME
9
Explain the care of clients with retention catheters or urinary diversions.
Concepts for Lecture
1. Nursing care of the client with an indwelling catheter and continuous
drainage is largely directed toward preventing infection of the
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have the students review current evidence-based
practice related to prevention of urinary tract
infections and develop an information sheet for
clients based on their findings.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Invite a staff nurse to discuss practices used to
prevent urinary tract infections for clients on
the clinical unit.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Review the Centers for Disease Control (CDC)
recommendations for care of clients with reten-
tion catheters.
• Invite an ostomy nurse to discuss care of the
client who has a urinary ostomy.
• Show videotaped performance of the insertion of
straight and indwelling catheters and ostomy
care.
mL/day, if permitted, to flush the bladder and decrease the likelihood
of urinary stasis, infection, and the risk of sediment obstructing the
urine. Conversely, most fruits, vegetables, legumes, milk, and milk
products result in alkaline urine.
For perineal care, no special cleaning other than routine hygiene
is necessary for clients with retention catheters.
Routine changing of the catheter and tubing is not
2. Ongoing assessment of clients with retention catheters is a high
priority. To maintain patency of the drainage system and prevent
contamination of the drainage system, the nurse should ensure that
there are no obstructions in the drainage tubing and that the drainage
3.
When caring for clients with a urinary diversion, the nurse must accu-
rately assess intake and output; note any changes in urine color, odor, or
L
EARNING
O
UTCOME
10
Verbalize the steps used in:
a. Applying an external urinary device
b. Performing urinary catheterization
c. Performing bladder irrigation
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Invite a dietician to discuss appropriate foods
•
Review the agency’s procedures for catheteri-
zation, and assign students to perform cathe-
terizations when possible.
362 CHAPTER 48 / Urinary Elimination
Concepts for Lecture
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 48–1: APPLYING AN EXTERNAL URINARY DEVICE
(CONDOM CATHETER)
COMPETENCY
DEMONSTRATED?
Yes
No
1.
Introduced self and verified the client’s identity.
2.
Explained the procedure to the client and discussed how the re-
sults will be used.
4.
Performed hand hygiene and observed other appropriate infection
control procedures.
5.
Applied clean gloves.
a. Draped the client appropriately with bath blanket, exposing only
the penis.
6.
Positioned the client in either supine or sitting position. Provided
7.
Inspected and cleaned the penis.
a. Cleansed the genital area and dried it thoroughly.
8.
Applied and secured the condom catheter.
connecting tube.
penis.
a. Rolled the condom catheter smoothly over the penis and left 2.5
9.
Securely attached the urinary drainage system.
catheter and that the condom catheter was not twisted.
b. Attached the urinary drainage system to the condom catheter.
a. Ensured that the tip of the penis was not touching the condom
10. Securely attached the urinary drainage system to the bed frame.
11. Taught the client about the drainage system.
a. Instructed the client to keep the drainage bag below the level of
the condom catheter and to avoid loops or kinks in the tubing.
12.
Inspected the penis 30 minutes following the condom application,
and at least every 4 hours. Checked the urine flow.
13.
Changed the condom catheter as indicated, and provided skin
care.
a. Removed the flexible tape or Velcro strip, applied clean gloves,
and rolled off the condom catheter.
b. Cleansed the penis with soapy water, rinsed, and dried
thoroughly.
c. Assessed the foreskin for signs of irritation, swelling, and
discoloration.
d. Reapplied a new condom catheter.
CHAPTER 48 / Urinary Elimination 363
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 48–2: PERFORMING URINARY
CATHETERIZATION
COMPETENCY
DEMONSTRATED?
Yes
No
2. Explained the procedure to the client and discussed how the results
will be used.
4. Performed hand hygiene and observed other appropriate infection
control procedures.
6. Placed client in the appropriate position and draped all areas except
perineum.
7. Established adequate lighting. Stood on the client’s right if nurse is
right-handed and on left if nurse is left-handed.
8. If using a collecting bag and it was not contained in catheterization
kit, opened drainage package and placed end of tubing within reach.
discarded gloves. Performed hand hygiene.
9. If agency policy permitted, applied clean gloves and injected 10–15
mL xylocaine gel or water-soluble lubricant into the urethra of both
10. Opened the catheterization kit. Placed a waterproof drape under
11. Applied sterile gloves.
12. Organized the remaining supplies:
a. Saturated cleansing balls with antiseptic solution.
and tested the balloon.
14. Lubricated the catheter (1–2″ for females, 6–7″ for males) and placed
it with the drainage end inside the collection container.
15. If desired, placed the fenestrated drape over the perineum, exposing
the urinary meatus.
16. Cleansed the meatus.
a. For women: Spread the labia with nondominant hand. Did not
allow the labia to close over cleaned meatus. Cleansed in antero-
17. Inserted the catheter.
b. Advanced the catheter 2 in. farther after urine began to flow
tissue before entering meatus, performed catheterization with a
a. Grasped catheter firmly 5 to 7.5 cm (2 to 3 in.) from tip. Asked
the client to take a slow deep breath and inserted the catheter as
18. Held the catheter with nondominant hand.
19. For an indwelling catheter, inflated the retention balloon to the desig-
nated volume.
the two fingers of the nondominant hand while the nurse attached
20. Collected a urine specimen if needed.
21. Allowed the straight catheter to continue draining into the urine re-
ceptacle.
22. Examined and measured the urine.
23. Removed the straight catheter when urine flow stopped.
b. Secured collecting tubing to bed linens and hung bag below
a. Secured an indwelling catheter to the female client’s thigh or the
fortable position. Instructed the client on positioning and moving with
the catheter in place.
24. Wiped the perineal area of any remaining antiseptic or lubricant.
25. Discarded all used supplies in the appropriate receptacles.
26. Removed and discarded gloves. Performed hand hygiene.
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 48–3 PERFORMING BLADDER IRRIGATION
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified the client’s identity.
2. Explained the procedure to the client and discussed how the results
will be used.
3. Gathered the appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
control procedures.
5. Provided for client privacy.
6. Applied clean gloves.
present in the drainage bag. Discarded the urine and gloves.
8. Prepared the equipment.
a. Performed hand hygiene.
c. Applied clean gloves and cleansed the port with antiseptic swabs.
catheter.
e. Connected the drainage bag and tubing to the urinary drainage
port, if not already in place.
f. Removed and discarded gloves. Performed hand hygiene.
9. Irrigated the bladder.
the infusion tubing.
a. For closed continuous bladder irrigation using a three-way catheter,
opened the clamp on the urinary drainage tubing. Applied clean
gloves. Opened the regulating clamp on the irrigating fluid infusion
c. If a two-way catheter was used, used an irrigating syringe with
needleless adapter to instill solution.
10. Assessed the client and the urinary output.
a. Assessed the client’s comfort.
b. Emptied the drainage bag and measured its contents. Subtracted
the amount of irrigant instilled from the total volume of drainage.
c. Removed and discarded gloves. Performed hand hygiene.
1. Assembled the equipment. Used an irrigation set or assembled indi-
vidual items.
2. Prepared the client.
3. Prepared the equipment.
a. Performed hand hygiene.
gating solution into a sterile basin or receptacle.
c. Placed disposable water-resistant towel under the catheter.
the end of the drainage tube.
f. Drew prescribed amount of irrigating solution into the syringe,
maintaining the sterility of the syringe and the solution.
b. Used aseptic technique, opened the supplies and poured the irri-
4. Irrigated the bladder.
a. Inserted the tip of the syringe into the catheter opening.
b. Gently and slowly injected the correct amount of the solution into
the catheter at approximately 3 mL per second.
c. Removed the syringe and allowed the solution to drain back into
the basin.
d. Continued to irrigate the client’s bladder until the total amount to
be instilled had been injected.
366 CHAPTER 48 / Urinary Elimination
e. Removed the protective cap from the drainage tube and wiped
with an antiseptic swab.
L
EARNING
O
UTCOME
11
Recognize when it is appropriate to delegate aspects of urinary elimination to
unlicensed assistive personnel.
Concepts for Lecture
1. Applying a condom catheter may be delegated to unlicensed assis-
tive personnel (UAP). However, the nurse must determine if the spe-
2. Due to the need for sterile technique and detailed knowledge of
L
EARNING
O
UTCOME
12
Demonstrate the appropriate documentation and reporting of application of
an external catheter, performing urethral urinary catheterization, and per-
forming bladder irrigation.
Concepts for Lecture
1. Inspect the penis 30 minutes following the condom catheter applica-
tion and at least every 4 hours. Check the urine flow. Document any
2. Document the catheterization procedure, including catheter size and