Eliminating waste is a physical need. The digestive system rids the body of solid wastes. The lungs remove carbon dioxide. Sweat contains water and other substances. Blood contains waste products from body cells burning food for energy. The urinary system removes waste products from the blood. It also maintains the body’s water and electrolyte balance.

See Body Structure and Function Review: The Urinary System.

See Promoting Safety and Comfort: Urinary Elimination.

Body Structure and Function Review

The Urinary System

The 2 kidneys (Fig. 24-1) lie in the upper abdomen against the back muscles on each side of the spine. Blood passes through the 2 kidneys. Urine is formed in the kidneys.

Urine consists of wastes and excess fluids filtered out of the blood. Urine flows through the 2 ureters to the urinary bladder. Urine is stored in the bladder. The urethra connects the bladder to the outside of the body. The opening at the end of the urethra is called the meatus. Urine passes from the body through the meatus. Urine is a clear, yellowish fluid.

See Chapter 10 for more information.

Promoting Safety and Comfort

Urinary Elimination

Safety

Urinary elimination measures often involve exposing and touching private areas—the perineum and rectum. Sexual abuse has occurred in health care settings. The person may feel threatened or may actually be abused. He or she needs to call for help. Keep the call light within the person’s reach at all times. And always act in a professional manner.

Urine may contain blood and microbes. Microbes can live and grow in bedpans, urinals, commodes, and urinary drainage bags (Chapter 25). Follow Standard Precautions and the Bloodborne Pathogen Standard (Chapter 16) to handle urinary devices and their contents. This includes incontinence products. Thoroughly clean and disinfect bedpans, urinals, and commodes after use. Remember to practice hand hygiene.

Normal Urination

The healthy adult produces 1500 mL (milliliters) or 3 pints of urine a day. Many factors affect urine production—age, disease, the amount and kinds of fluid ingested, salt, body temperature, perspiration (sweating), and some drugs. Some substances increase urine production—coffee, tea, alcohol, and some drugs. A diet high in salt causes the body to retain water. So do some drugs. When water is retained, less urine is produced.

Urination (micturition and voiding) means the process of emptying urine from the bladder. The amount of fluid intake, habits, and available toilet facilities affect frequency. So do activity, work, and illness. People usually void at bedtime, after sleep, and before meals. Some people void every 2 to 3 hours. Voiding at night disturbs sleep.

Some persons need help getting to the bathroom. Others use bedpans, urinals, or commodes. Follow the rules in Box 24-1 and the person’s care plan.

Box 24-1

Rules for Normal Urination

• Practice medical asepsis.

• Follow Standard Precautions and the Bloodborne Pathogen Standard.

• Provide fluids as the nurse and care plan direct.

• Follow the person’s voiding routines and habits. Check with the nurse and the care plan.

• Help the person to the bathroom upon request. Or provide the commode, bedpan, or urinal. The need to void may be urgent.

• Help the person assume a normal position for voiding if possible. Women sit or squat. Men stand.

• Warm the bedpan or urinal.

• Cover the person for warmth and privacy.

• Provide for privacy. Pull the privacy curtain around the bed, close room and bathroom doors, and close window coverings. Leave the room if the person can be alone.

• Tell the person that running water, flushing the toilet, or playing music can mask voiding sounds. Voiding with others nearby embarrasses some people.

• Stay nearby if the person is weak or unsteady.

• Place the call light and toilet tissue within reach.

• Allow enough time. Do not rush the person.

• Promote relaxation. Some people like to read.

• Run water in a sink if the person cannot start the urine stream. Or place the person’s fingers in warm water.

• Provide perineal care as needed (Chapter 22).

• Assist with hand-washing after voiding. Provide a wash basin, soap, washcloth, and towel.

• Assist the person to the bathroom or offer the bedpan, urinal, or commode at regular times. Some people are embarrassed or are too weak to ask for help.

See Focus on Communication: Normal Urination, p. 390.

See Focus on Children and Older Persons: Normal Urination, p. 390.

See Teamwork and Time Management: Normal Urination, p. 390.

Focus on Communication

Normal Urination

Patients and residents may not use “voiding” or “urinating” terms. The person may not understand what you are saying. Do not ask: “Do you need to void?” or “Do you need to urinate?” Instead, you can ask these questions.

• “Do you need to use the bathroom?”

• “Do you need to use the bedpan (urinal)?”

• “Do you need to pass urine?”

• “Do you need to pass water?”

• “Do you need to pee?”

The word “pee” may offend some persons. Choose words the person understands and uses. Follow the care plan.

Focus on Children and Older Persons

Normal Urination

Children

Infants produce 200 to 300 mL of urine a day. The amount increases as the baby grows older. An infant can have 6 to 20 wet diapers a day. Tell the nurse at once if an infant does not have a wet diaper for several hours. This signals dehydration. It is very serious in infants.

Teamwork and Time Management

Normal Urination

The need to void may be urgent. Answer call lights promptly. Also, answer call lights for co-workers. Otherwise incontinence may result. The person is wet and embarrassed. Skin breakdown and infection are risks. Your co-worker has extra work—changing wet linens and garments. You like help when busy. So do your co-workers.

Observations

Normal urine is pale yellow, straw-colored, or amber (Fig. 24-2). It is clear with no particles. A faint odor is normal. Observe urine for color, clarity, odor, amount (output), particles, and blood.

FIGURE 24-2 Color chart for urine. (Redrawn from Weldon, Inc., Fort Worth, Tex.)

Red food dyes, beets, blackberries, and rhubarb cause red-colored urine. Carrots and sweet potatoes cause bright yellow urine. Certain drugs change urine color. Asparagus causes a urine odor.

Ask the nurse to observe urine that looks or smells abnormal. Report the problems in Table 24-1. The nurse uses the information for the nursing process.

TABLE 24-1

Urinary Elimination Problems

Problem	Definition	Causes
Dysuria	Painful or difficult (dys) urination (uria); burning on urination	Urinary tract infection (UTI), trauma, urinary tract obstruction
Hematuria	Blood (hemat) in the urine (uria)	Kidney disease, UTI, trauma
Nocturia	Frequent urination (uria) at night (noc)	Excess fluid intake, kidney disease, prostate disease
Oliguria	Scant amount (olig) of urine (uria); less than 500 mL in 24 hours	Poor fluid intake, shock, burns, kidney disease, heart failure
Polyuria	Abnormally large amounts (poly) of urine (uria)	Drugs, excess fluid intake, diabetes, hormone imbalance
Urinary frequency	Voiding at frequent intervals	Excess fluid intake, UTI, pressure on the bladder, drugs
Urinary incontinence	The involuntary loss or leakage of urine	Trauma, disease, UTI, reproductive or urinary tract surgeries, aging, fecal impaction, constipation, not getting to the bathroom in time
Urinary retention	The inability to void	Prostate problems, nerve damage, UTI, drugs, surgery, kidney stones, constipation, trauma
Urinary urgency	The need to void at once	UTI, fear of incontinence, full bladder, stress

Bedpans

Bedpans are used by persons who cannot be out of bed. Women use bedpans for voiding and bowel movements (BMs). Men use them for BMs.

The standard bedpan is shown in Figure 24-3. The wide rim is placed under the buttocks. A fracture pan has a thin rim. It is only about -inch deep at one end (see Fig. 24-3). The smaller end (flat end) is placed under the buttocks (Fig. 24-4). Fracture pans are used:

• By persons with casts

• By persons in traction

• By persons with limited back motion

• By older persons with osteoporosis (fragile bones) or arthritis (Chapter 44)

• After spinal cord injury or surgery

• After a hip fracture

• After hip replacement surgery

FIGURE 24-3 Standard bedpan (left) and the fracture pan (right).

FIGURE 24-4 A person positioned on a fracture pan. The small end (flat end) is under the buttocks.

Like a fracture pan, the small end (flat end) of a bariatric bedpan is placed under the buttocks (Fig. 24-5). Some have a weight capacity of 1200 pounds.

FIGURE 24-5 Bariatric bedpan. (Image courtesy AliMed, Inc., Dedham, Mass.)

See Delegation Guidelines: Bedpans.

See Promoting Safety and Comfort: Bedpans.

See procedure: Giving the Bedpan, p. 392.

Delegation Guidelines

Bedpans

To assist with a bedpan, you need this information from the nurse and the care plan.

Promoting Safety and Comfort

Bedpans

Safety

Remember to raise the bed as needed for good body mechanics. Lower the bed before leaving the room. Raise or lower the bed rails according to the care plan.

Comfort

Most bedpans are plastic. Metal bedpans are often cold. Warm metal bedpans with warm water and then dry them before use.

The person must not sit on a bedpan for a long time. Bedpans are uncomfortable. They can lead to pressure ulcers from prolonged pressure (Chapter 37).

Giving the Bedpan

Quality of Life

• Knock before entering the person’s room.

• Address the person by name.

• Introduce yourself by name and title.

• Explain the procedure before starting and during the procedure.

• Protect the person’s rights during the procedure.

• Handle the person gently during the procedure.

Pre-Procedure

1. Follow Delegation Guidelines: Bedpans, p. 391. See Promoting Safety and Comfort:

a Urinary Elimination, p. 389

b Bedpans, p. 391

2. Provide for privacy.

3. Practice hand hygiene.

4. Put on gloves.

5. Collect the following.

• Bedpan

• Bedpan cover

• Toilet tissue

• Waterproof under-pad (if required by agency policy)

6. Arrange equipment on the chair or bed.

Procedure

7. Lower the bed rail near you (if up).

8. Lower the head of the bed. Position the person supine. Or raise the head of the bed slightly for the person’s comfort.

9. Fold the top linens and gown out of the way. Keep the lower body covered.

10. Ask the person to flex the knees and raise the buttocks. He or she does so by pushing against the mattress with the feet.

11. Slide your hand under the lower back. Help raise the buttocks. If using a waterproof under-pad, place it under the buttocks.

12. Slide the bedpan under the person (Fig. 24-6).

FIGURE 24-6 The person raises the buttocks off the bed with help. The bedpan is slid under the person.

13. If the person cannot assist in getting on the bedpan:

a Place the waterproof under-pad under the buttocks if using one.

b Turn the person onto the side away from you.

c Place the bedpan firmly against the buttocks (Fig. 24-7).

FIGURE 24-7 Giving a bedpan. A, Position the person on the side away from you. Place the bedpan firmly against the buttocks. B, Push downward on the bedpan and toward the person.

d Hold the bedpan securely. Turn the person onto his or her back.

e Make sure the bedpan is centered under the person.

14. Cover the person.

15. Raise the head of the bed so the person is in a sitting position (Fowler’s position) for a standard bedpan. (NOTE: Some state competency tests require removing gloves and hand-washing before you raise the head of the bed.)

16. Make sure the person is correctly positioned on the bedpan (Fig. 24-8).

FIGURE 24-8 The person is positioned on the bedpan so the urethra and anus are directly over the opening.

17. Raise the bed rail if used.

18. Place the toilet tissue and call light within reach. (NOTE: For some state competency tests you ask the person to use hand wipes to clean the hands after wiping with toilet tissue.)

19. Ask the person to signal when done or when help is needed.

20. Remove and discard the gloves. Practice hand hygiene.

21. Leave the room and close the door.

22. Return when the person signals. Or check on the person every 5 minutes. Knock before entering.

23. Practice hand hygiene. Put on gloves.

24. Raise the bed for body mechanics. Lower the bed rail (if used) and lower the head of the bed.

25. Ask the person to raise the buttocks. Remove the bedpan. Or hold the bedpan and turn him or her onto the side away from you.

26. Clean the genital area if the person cannot do so.

a Clean from the meatus (front or top) to the anus (back or bottom) with toilet tissue. Use fresh tissue for each wipe.

b Provide perineal care if needed.

c Remove and discard the waterproof under-pad if using one.

27. Cover the bedpan. Take it to the bathroom. Raise the bed rail (if used) before leaving the bedside.

28. Note the color, amount (output), and character of urine or feces. See “Measuring Intake and Output” in Chapter 27.

29. Empty the bedpan contents into the toilet and flush.

30. Rinse the bedpan. Pour the rinse into the toilet and flush.

31. Clean the bedpan with a disinfectant. Pour disinfectant into the toilet and flush.

32. Remove and discard the gloves. Practice hand hygiene and put on clean gloves.

33. Return the bedpan and clean cover to the bedside stand.

34. Help the person with hand-washing. (Wear gloves for this step.)

35. Remove and discard the gloves. Practice hand hygiene.

Post-Procedure

36. Provide for comfort. (See the inside of the front cover.)

37. Place the call light and other needed items within reach.

38. Lower the bed to a safe and comfortable level for the person. Follow the care plan.

39. Raise or lower bed rails. Follow the care plan.

40. Unscreen the person.

41. Complete a safety check of the room. (See the inside of the front cover.)

42. Follow agency policy for used linens.

43. Practice hand hygiene.

44. Report and record your observations.

Urinals

Men use urinals to void (Fig. 24-9, p. 394). Plastic urinals have caps and hook-type handles. The urinal hooks to the bed rail within the man’s reach. He stands to use the urinal if possible. Or he sits on the side of the bed or lies in bed to use it. Some men need support when standing.

After voiding, the urinal cap is closed. This prevents urine spills. Remind men to hang urinals on bed rails and to signal after using them. Remind them not to place urinals on over-bed tables and bedside stands. Over-bed tables are used for eating and as a work surface. Bedside stands are used for personal items and supplies. These surfaces must not be contaminated with urine.

Some beds may not have bed rails. Follow agency policy for where to place urinals.

See Focus on Communication: Urinals, p. 394.

See Delegation Guidelines: Urinals, p. 394.

See Promoting Safety and Comfort: Urinals, p. 394.

See procedure: Giving the Urinal, p. 394.

Focus on Communication

Urinals

Some men cannot use a urinal on their own. You may need to assist. Or you may need to stay with the person. For the person’s comfort, explain why you must help him. You can say: