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Urinary Elimination

Professional Nursing

Function of the urethra: is to convey urine from the bladder to the exterior of the body.
Enuresis Intentional or involuntary urination into bed or clothes that occurs after an age when continence should be present
Patients with reflex incontinence: experience emptying of the bladder without the sensation of the need to void.
Nephron: is the basic structural and functional unit of the kidneys.
Incontinence that results from weakness of the pelvic floor muscles can be treated by teaching the patient to perform: Kegel exercises.
A urinary diversion: involves the surgical creation of an alternate route for excretion of urine.
The specific gravity of urine: is a measure of the density of urine compared with the density of water.
If a catheter is to remain in place for continuous drainage: an Indwelling urinary catheter is used.
Kidneys and Ureters: Maintain composition and volume of body fluids. Filter and excrete blood constituents not needed; retain those that are needed. Excrete waste product (urine).
Nephrons: remove the end products of metabolism and regulate fluid balance. Urine from the nephrons empties into the kidneys.
Bladder: Smooth muscle sac, reservoir for urine. Has three layers of muscle tissue called detrusor muscle. Sphincter guards opening between urinary bladder and urethra. Urethra conveys urine from bladder to exterior of body.
Detrusor muscle: inner longitudinal, middle, and outer longitudinal
Bladder: Hollow, distendable muscular organ that functions as a reservoir for urine. It lies behind the symphysis pubis. In the male the posterior wall of the bladder rests against the rectum- in females it rests against the vagina and uterus.
Sympathetic System: carries inhibitory impulses to the bladder and motor impulses to the internal sphincter. Impulses cause the detrusor muscle to relax and the internal sphinchter to constrict, retaining urine in the bladder.
Parasympathetic System: carries motor impulses to the bladder and inhibitor impulses to the internal sphincter. Causes the detrusor muscle to contract and the sphincter to relax.
Urethra: Transport urine from the bladder to the exterior. Male urethra functions in excretory and reproductive systems. No portion of female urethra is external to the body.
Characteristics of normal urine: amount, color, clarity, odor
Amount: 1,200-1700 mL daily- average 1,500mL
Color: pale straw color to amber
Clarity: transparent, becomes cloudy after a few minutes
Odor: mild aromatic, changes when exposed to air- ammonia odor due to bacterial action; food and medications can affect odor.
Micturition: voiding, urination, emptying the bladder. process of emptying the bladder. Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra. Muscles of perineum and external sphincter relax. Muscle of abdominal wall contracts slightly. Diaphragm lowers, micturition occurs.
Capacity of the bladder: varies from 600-1,000mL
If a patient complains of secondary enuresis (wetting the bed after being trained) your first thought should be: Type 1 Diabetes.
Diseases associated with Renal problems: Congenital urinary tract abnormalities. Polycystic kidney disease. Urinary tract infection. Urinary calculi. Hypertension. Diabetes mellitus. Gout. Connective tissue disorders.
Diuretics: prevent reabsorption of water and certain electrolytes in tubules.
Cholinergic medications stimulate contraction of detrusor muscle, producing urination.
Analgesics and tranquilizers: suppress CNS, diminish effectiveness of neural reflex.
Nephrotoxicity: Prescription and nonprescription medications which cause kidney damage are known to be nephrotoxic. Examples of these meds are: aspirin, ibuprofen, gentamicin.
Diuretics: used to treat HTN – prevent reabsorption of Ho and certain electorlytes in the tubules. Cause moderate to severe increases in production and excretion of dilute urine.
Anticoagulants: may cause hematuria (blood in the urine) pink or red tinged
Diuretics: lighten the color (pale yellow)
Pyridium: (a urinary tract analgesic) can cause orange or red-orange urine
Elavil: Elavil or B-complex vitamins – cause the urine to be green or blue – green
Levodopa: (anti-parkinson drug) and injectable iron compound – lead ot brown or black urine
Physical Assessment of Urinary Functioning: Kidneys, Urinary Bladder, Urethral Meatus, Skin, Urine
Kidneys: check for costovertebral tenderness
Urinary Bladder: bladder—palpate and percuss the bladder or use bedside scanner
Urethral Meatus: meatus—inspect for signs of infection/inflammation, discharge, or odor
Skin: assess for color, texture, turgor, and excretion of wastes
Urine: assess for color, odor, clarity, and sediment
Urine Specimens: Routine urinalysis, Specimens from infants and children, Clean-catch or midstream specimens, Sterile specimens from indwelling catheter, 24-hour urine specimen
Routine Urinalysis: Sterile specimen is not required. Collect urine in a clean bedpan, urinal or receptacle. Using aseptic technique, pour the urine into an appropriate container. Do not leave urine standing at room temperature – may alter chemistry/appearance.
Specimens from infants/children: Plastic disposable collection bags are available to collect specimens. Be careful when removing to avoid irritating the sensitive perineal area.
Clean catch/midstream specimen: During midstream. Most characteristics of the urine the body is producing. First amount of urine helps to flush away any organisms near the meatus.
Sterile specimens from indwelling catheter: Catheterizing a patient’s bladder/by taking a sample from an indwelling catheter. Use specimen port on indwelling catheter. The drainage bag may not be fresh urine. Use a syringe, antiseptic swab, sterile specimen container, non-sterile gloves, clamp.
24-hour urine specimen: Discard the urine and collect all the urine for 24 hours (documenting start time). Send entire specimen to lab. May be held separately with each void and labeled or put together. May need to keep in the refrigerator or on ice.
Assessing for Renal Function: Urinalysis and Chemistry
Urinalysis: pH, protein, glucose, ketones, blood, specific gravity, WBCs, cast
pH: 4.6-8.0 usually a 6. If it stands for several hours it becomes increasingly alkaline due to bacteria. Diet also affects pH.
Protein: 0-10 mg/100 mL increased in renal disease, elevated temp, stress, increased PO intake, strenuous exercise and cold.
Glucose: 0 increased in poorly controlled DM with BG>180 mg/dl spill sugar into urine.
Ketones: 0 increased in poorly controlled DM, starvation, excessive ASA ingestion. Ketones come from incomplete breakdown of fatty acids.
Blood: < 2RBC increase in kidney damage, female with period “contaminates the urine".
Specific Gravity: 1.010 – 1.030 Measures the density of the urine compared with density of water.
WBCs: 0-8 increased in infection.
Cast: 0 Casts are the result of solidification of material (protein) in the lumen of the kidney tubules, more specifically in the nephron.
Chemistry: BUN and Serum Creatinine
BUN: 10- 30 mg/dl measures kidney function. Increases in renal disease, fever, diabetes, and increased adrenal gland activity. End product of protein metabolism and is formed with CO2 in the liver – the amount excreted varies with protein intake.
Serum Creatinine: 0.5 – 1.5 mg/dl product of muscle metabolism filtered by the kidneys. Indicator of renal disease. W/ decreased kidney function, less creatinine is excreted and serum level increases.
Specific Gravity: Measures the density of the urine compared with density of water. The higher the number, the more concentrated the urine is unless there are abnormal components (glucose, or protein).
Measure of Concentration: Specific Gravity It increases w/ dehydration, decreased renal blood flow and increased ADH (antidiuretic hormone – Vasopressin). It decreases w/ over hydration (fluid overload), decreased ADH, and inability of kidneys to concentrate urine.
Vasopressin: is responsible for regulating the body's retention of water by acting to increase water absorption in the collecting ducts of the kidney nephron.
To determine specific gravity: read the urinometer at eye level at the base of the meniscus formed by the urine.
Urodynamic Studies: Group of test that measures how the urine flows, is stored, and is eliminated in the lower urinary tract. Identifies abnormal voiding patterns in persons with incontinence or inability to void normally.
KUB: (bladder should be full before the test) x-ray of the abdomen, sometimes called a “flat plate” of the abdomen. No preparation and no post procedure care. It will show size and shape of the kidneys, ureters, and bladder –stones will also be visible.  
Cystoscopy: the direct visual exam of the bladder, uretheral orifices, and urethra with a cystoscope.
Cystoscopy - invasive procedure: Used to diagnose disorders of lower urinary tract, interior bladder, urethra, male prostatic urethra and ureteral orifices. Procedure done w/ pt in lithotomy position a lighted scope is inserted into bladder under local, spinal/ general anesthesia.
Purpose of Cystoscopy: obtain biopsies, remove stones/foreign bodies, implant radium seeds etc. Preparation depends on type of anesthesia-may also bowl cleanse.
Post Procedure: urine maybe pink tinged or an unusual color if dye was used, may experience burning on urination, back pain, bladder spasms and feeling of fullness-warm bathes and mild analgesics usually provide relief-encourage increased fluid intake.
Complications of Cystoscopy: include infection, bleeding and retention.
IVP (intravenous pylogram): IV based dye is given via IV infusion through x-ray visualize entire urinary tract over 1-2 hour period. PURPOSE - identifies tumors, cysts, renal artery occlusion, calculi, trauma, vesicoureteral reflux.
IVP (intravenous pylogram) Side Effects: facial flushing, salty taste in mouth, warmth, and dizziness are normal sensations.
IVP (intravenous pylogram): PREPARATION- includes NPO and bowel prep (KUB are behind the intestines). POST procedure- monitor for dye reactions- drink additional fluids.
Retrograde Pylogram: Passage of small catheter through a cystoscope into ureter into renal pelvis. Small amt of dye is injected through catheter, x-rays are taken to outline collecting system. As the catheter is out more dye is injected, outline of the ureter is seen.
Retrograde Pylogram: PURPOSE - view renal collecting system and ureters-can be used if person allergic to dye as it isn’t absorbed systemically. NPO after midnight. Contraindicated with pregnancy and Iodine allergy. Give laxative the night before.
Ultrasonography (ultrasound): Non invasive procedure involving the projection of high frequency waves into the abdomen which bounce back and give an oscilloscope image of underlying structures. Instantly developed pictures may be taken of theses images.
Ultrasonography (ultrasound) - purpose: Purpose - can distinguish cysts from solid masses, see urine in bladder, calculi, or map an organ (kidney) for a needle biopsy. No special preparation or aftercare. Restrict fluids,food for 8-12 hrs before ultrasound.
Urinary Tract Infection: (UTI) Leading cause of morbidity and healthcare expenditures in persons of all ages. Leading cause of systemic infection in older adults. Women are more vulnerable to UTI. E. Coli found in the GI tract is the most common causal organism.
Pyelonephritis: Upper tract infection involves kidneys and ureter.
Cystitis: Lower tract infection involves bladder and urethra.
Signs & Symptoms of UTI: Dysuria, frequency, urgency, voiding small amounts. Cloudy urine or hematuria. Lower back or suprapubic pain. Fever & malaise Older adult -> Confusion, falls, incontinence, fever, anorexia, nocturia, dysuria.
UTI Diagnosis: Bacterial count > 100,000/mL plus symptoms
Patients at Risk for UTI: Sexually active women, Women who use diaphragms for contraception, Postmenopausal women, Individuals with indwelling urinary catheter, Individuals with diabetes mellitus, Elderly people
Sexually Active Women: during intercourse, perineal bacteria can migrate into the urethra and bladder.
Women who use diaphragms for contraception: spermicide used with diaphragms decrease the amount of normal protective flora.
Postmenopausal Women: urinary stasis, (common at this age) provides an optimal environment for bacteria to multiply. Decreased Estrogen contributes to loss of protective vaginal flora.
Individuals with indwelling catheter: about ½ get infected within 1 week after insertion. Break in sterile technique during placement can lead to infection, most pathogens are introduced via handling of the catheter and draining device after placement.
Diabetes Mellitus: glucose in the urine acts as an excellent medium for bacteria.
Elderly People: the physiologic changes associated with aging predispose people to develop UTI.
Treatment for UTIs: antibiotics, patient education. Short course antibiotics –> works on lower tract infections. Long course antibiotics –> required for upper tract infections.
Reasons for Catheterization: Relieving urinary retention. Obtaining a sterile urine specimen. Obtaining a urine specimen when usual methods can’t be used. Emptying bladder before, during, or after surgery. Monitoring critically ill patients.
Intermittent urethral catheter or straight catheters: Ssed to drain the bladder for shorter periods. Can be performed by pt or caregiver at home. “recommended at regular intervals to prevent over distension of the bladder and decreased blood flow through the wall of the bladder.
Indwelling Urethral Catheter: Retention or Foley catheter. Designed so it does not slip out of the bladder. The balloon is inflated once it is inserted. Used for gradual decompression of an over distended bladder, for intermittent or continuous drainage.
Suprapubic Catheter: long term continuous drainage – inserted surgically. Diverts urine from urethra when there is a stricture, injury, prostatic obstruction, gynecologic or abdominal surgery has compromised the flow of urine to urethra.
Urinary Stent: Used in patients with urinary obstruction. Stent is temporary –> placed in ureters. Stent is permanent –> placed in urethra. Placed with local anesthesia and sedation with cystoscopy.
Ileal Conduit: Urine is diverted surgically. Because of tumor or obstruction in the urinary tract. Surgical resection of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma.
Dialysis: a mechanical way of filtering waste from the body. Used to treat patients with severely decreased or total loss of kidney function. Two types of dialysis: Hemodialysis and Peritoneal dialysis.
Hemodialysis: Machine works for the kidneys by filtering out harmful wastes and electrolytes and fluid from the blood that would normally be eliminated in the urine. Patient has vascular access to allow for access to the blood (AV fistula, AV graft)
AV fistula: arteriovenous – surgically created between the artery and vein.
AV graft: Graft – surgically created path between an artery and vein using flexible, synthetic tube.
Peritoneal Dialysis: Involves blood vessels in the abdominal lining (peritoneum) to fill in the kidneys, with the help of fluid (dialysate) washed in and out of the peritoneal space. Catheter is surgically placed through the abdomen in to the peritoneal cavity.
Created by: mr209368