Fundamentals - Practice & Skills, part 22: Urinary Specimen Collection, Incontinence, and Urinary Tract Infections
by Meris Shuwarger August 16, 2021 Updated: April 05, 2022 11 min read
This article covers urine characteristics, urinary specimen collection, urinary incontinence, and urinary tract infections (UTIs). You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
The following are the expected characteristics of urine — its normal values and limits.
Daily urine output should equal daily fluid intake. The expected output ranges from 0.5 – 1.5 mL/kg/hr or approximately 1,500 mL/day.
Alert provider for urine output less than 30 mL/hr. This could indicate that the patient has severe oliguria (not a lot of urine).
The color of normal urine ranges from light yellow (straw-colored) to amber.
Urine should be clear (transparent, not cloudy). It should not be malodorous, which could indicate a health issue.
Urine should not contain: glucose, ketones (an indicator of diabetic ketoacidosis or "DKA"), blood, protein, bilirubin, nitrates, or leukocyte esterase (a screening test used to detect white blood cells in the urine).
Urine specific gravity
Specific gravity is a measurement used in urinalysis and describes the concentration level of the urine. The normal range is 1.005 to 1.030.
DiLute = Low urine specific gravity.
You can learn more about the normal value ranges for urine, including output, specific gravity and more, with our Lab Values Study Guide & Flashcard Index, a list of lab values covered in depth in our Lab Values Flashcards for nursing students.
Urine sample collection
Urine specimens may be collected in a number of ways, often by the patient. These include routine urinalysis, clean catch, sterile specimens, and 24-hour urine specimen collection.
A routine urinalysis is collected during normal voiding. Note that when collecting a pure urine sample, avoid contamination with feces.
If the sample cannot be analyzed within 1 hour, refrigerate it.
Clean catch urine specimen
In a clean catch urine specimen, the patient collects the sample while they are urinating. Generally, clean the penis or vulva with sterile moist wipes. Waste the initial amount into the toilet, then position the sterile container into the stream to collect the urine. Only 15 – 30 mL is needed for analysis.
There are different teachings for those with a penis and those with a vulva.
Clean catch specimen collection for a male (penis)
If a patient has a penis and is uncircumcised, teach them to retract the foreskin and then clean around the urethral meatus (the opening of the urethra) in concentric circles. They should replace the foreskin after they are done urinating.
Clean catch specimen collection for a female (vulva)
For a patient with a vulva, they should separate the labia so that the urethral opening is exposed and clean the area from front to back using sterile wipes (usually Castile soap wipes). This is to clean away any kind of grime or dead skin cells from the area to allow for the collection of a cleaner sample. When urinating, they should hold the labia apart.
Note that patients should always begin urinating into the toilet, stop, then urinate into the collection cup, stop, and then finish urinating into the toilet. This is called midstream clean catch.
Sterile urine specimen
Sometimes a sterile environment is required, and that can mean catheterizing the patient or collecting from a special sampling port on an indwelling catheter. Never collect a sample from a drainage bag!
24-hour urine collection
24-hour urine collection is when the patient collects their urine for 24 hours in a designated container.
The most important patient teaching here is to discard the first void of the day (which is usually more concentrated and could adversely affect the lab results), then collect all of the urine voided in the next 24 hours.
Patients should be taught to keep the container refrigerated between sample collections.
Urinary incontinence is the loss of bladder control, leading to urine leakage. There are diverse reasons for urinary incontinence.
Stress incontinence is when there is a small urine leak as a result of increased intra-abdominal pressure. For example, when sneezing, coughing, or laughing, the pressure on the abdomen increases, which then puts pressure on the bladder, causing a small urine leak. The underlying cause of this condition is a weakened pelvic floor.
Risk factors for urinary stress incontinence
The risk factors for urinary stress incontinence include patients who have had multiple pelvic surgeries or patients who have had multiple pregnancies or deliveries of infants, both of which will weaken the pelvic floor muscles.
Obesity and menopause are further risk factors.
Urge incontinence is the inability to make it to the bathroom in time when feeling the urge to urinate. This is due to an overactive detrusor muscle (the smooth muscle in the bladder).
Risk factors for urinary urge incontinence
The risk factors for urinary stress incontinence include neurologic disorders (e.g., stroke) and bladder irritation.
Treatment for urinary incontinence
Treatments for urinary incontinence include behavioral and pharmacological therapies, as well as the use of mechanical devices.
These therapies include creating a toileting schedule or constipation management — regimens for creating consistent practices around voiding. Other behavioral therapies include Kegel exercises (training exercise to strengthen the pelvic floor), weight loss, and a decrease in caffeine and/or alcohol intake.
Mechanical devices such as cones or pessaries — devices that lift the bladder or apply compression to the urethra and can be inserted to maintain pressure and decrease the risk of urine leaking — may help treat urinary incontinence.
Urinary tract infection
A urinary tract infection is an infection in any part of the urinary tract. The most common type of UTI is a bladder infection (e.g., cystitis, an inflammation of the bladder).
Dealing with urinary tract infections is common in nursing practice, and it’s a topic that appears repeatedly in nursing school. The patient teaching for UTIs is, therefore, very important.
Risk factors for UTIs
People who have a vulva are most at risk for a UTI. The urethra is much shorter in a vulva than a penis, and there is close proximity of the urethral meatus to the anus. The penis, with its longer urethra, means it is harder (but not impossible) for bacteria to enter into the urinary stream.
Other risk factors for UTIs include Foley catheters (the most common type of indwelling urinary catheter), uncircumcised males, menopause, frequent sexual intercourse, and constipation.
Signs and symptoms for UTIs
The signs and symptoms for UTIs include abdominal pain, dysuria (painful urination), urinary frequency and urgency, nausea/vomiting, cloudy urine, a burning sensation when urinating, foul-smelling urine, and confusion (in older adults, who may not present classical symptoms).
A diagnosis of UTI will be if the urinalysis results are positive for bacteria, WBCs, leukocyte esterase, nitrates, or blood.
This information and more may also be found in the Renal System section of our Medical-Surgical Nursing Flashcards (Vol. 3).
Prevention of urinary tract infections
The prevention of urinary tract infections — and the patient teaching of preventative measures — is another important part of nursing school.
- Females, after urinating, wipe front to back — this is to prevent bringing fecal bacteria up to the urethra; also:
- Choose cotton underwear rather than artificial fabric; natural fibers are better at wicking moisture away and not trapping moisture, which bacteria love
- Avoid: bubble baths; sitting in wet bathing suits; tight clothing
- Uncircumcised males: clean under the foreskin after urinating
- Empty the bladder regularly
- Avoid constipation
- Urinate after vaginal penetrative intercourse
- Increase fluid intake: aim to drink 3 liters of fluid per day
- Cranberry juice: drinking cranberry juice can also help to decrease UTI symptoms
Hi. I'm Meris. And in this video, we're going to be talking about urine characteristics, urinary specimen collection, urinary incontinence, and urinary tract infections, UTIs. I'm going to be following along using our Fundamentals of Nursing flashcards. These are available on our website, leveluprn.com. And if you already have a set and you'd like to follow along with me, I'm starting on card number 115. Let's get started. So first up, let's just kind of talk about normal, expected characteristics of urine and things that we need to know as our normal values and limits. Our urine output should be, basically, 0.5 to 1.5 milliliters per kilogram per hour. Obviously, this is kind of just a big range. But in general, we are hoping to see about 1,500 mls, which is 1.5 liters per day of urinary output. We do, however, need to alert the provider if our patient's urinary output is ever less than 30 milliliters an hour. That's already below what the standard is for a patient's output. But that indicates that they are actually having severe oliguria, and that needs to be brought to the provider's attention.
Now, specific gravity is a measurement that you'll see reflected in urinalysis, and it talks about how concentrated urine is. So if we have a low specific gravity-- so our normal range is 1.005 to 1.030. Check the lab values deck if you want more on that. But if we have a low urine-specific gravity, this means that we have dilute urine, so it's not concentrated. So we do have a nice, cool, chicken hint here on this card, that dilute urine, with an L, dilute, is going to have low, with an L, specific gravity. So that's how you can remember those, because it can get confusing. Urine should be clear. So if it is hazy or cloudy or malodorous, if it smells bad, that's not a good thing. We want to consider that abnormal.
So moving on. Let's talk about the different types of urinary specimens that we can collect. And there's a lot of information on this part because we talk about routine urinalysis, clean catch, 24-hour urine specimen collection, sterile specimens, all of those things. But big ones I want to bring to your attention, a clean catch urine specimen. So this is going to be done by the patient while they are urinating. And we have different teaching for people who have a penis versus a vulva. If a patient has a penis and is uncircumcised, we need to teach him to retract the foreskin and then clean around the urethral meatus, the opening of the urethra. And then they should replace the foreskin after they're done urinating. If somebody has a vulva, though, we want them to separate the labia so that the urethral opening is exposed and clean from front to back using the designated wipes. Usually, these are Castile soap wipes, but they are going to clean away any kind of grime or dead skin cells from the area so we can get a really good look at what's going on.
No matter what, your patient should begin urinating into the toilet, stop, then urinate into the cup, stop, and then finish urinating into the toilet. This is called midstream clean catch. Another thing here that I want to bring your attention to is the 24-hour urine collection. This is going to be where the patient collects their urine for 24 hours in a designated container, but big patient teaching here is to discard the first void of the day. So if we're saying at 7:00 AM you need to start, so urinate at 7:00 AM and then start collecting the rest of the urine from then on. We don't want that from prior to 7:00 AM to be reflected in the collection. Make sure that they know to keep the container refrigerated as well.
All right. Moving on, let's talk about urinary incontinence. We've got a couple listed here, stress incontinence and urge incontinence. Stress incontinence is when there is urine leaking as a result of increased intra-abdominal pressure. What does this mean? It means when I cough or sneeze or jump or laugh really hard, the pressure in my abdomen's going to increase. And then that's going to put pressure on my bladder, which is going to let a little bit of urine leak. So who is most at risk for this? I'm going to ask you, and pause the video, all right? Okay. So I hope you paused the video. Who is most at risk for stress incontinence? It's going to be patients who have had multiple pelvic surgeries or patients who have had multiple pregnancies or deliveries of infants. That's going to weaken the pelvic floor muscles. Now, urge incontinence means I can't make it to the bathroom when I feel the urge to urinate. In either case, there's different treatments. We have pharmacological, so medications that can be prescribed. And then we also have things like physical therapy, pelvic floor therapy, and things like Kegel exercises, or Kegel exercises, depending on who you ask. And we also have mechanical devices like pessaries which can be inserted to put pressure and decrease the risk of urine leaking.
All right. Last up, let's talk about urinary tract infections. I would say this is one of the things for nursing school you got to know everything about. It just comes up time and time again. It's so common, and there's really important patient teaching. So who is most at risk? Pause the video. Think about it. All right. I hope you paused. Who's most at risk? It's going to be people who have a vulva. The urethra is much shorter if I have a vulva versus a penis. The penis has a longer urethra, so it's harder for bacteria to enter into the urinary stream. Now, that doesn't mean that those are the only people that can get it, but it is an important thing to keep in mind. Signs and symptoms are going to depend based on the patient, but big ones would be abdominal pain, dysuria, which means painful urination, frequency, and urgency, "I have to go to the bathroom all the time. I feel like I really have to go," burning and bad smell, malodorous urine. All of those are going to be big signs. But in the older adult, what is the biggest sign? The biggest sign is going to be confusion and abdominal pain. Very important to know. They may not present with classical symptoms. So we do have some information on how we can diagnose that, here on this card, including things to look for on the urine analysis, which will be very helpful for you. I'd also encourage you to check out that lab values stack for more information.
And then this card, card number 119, we talk about the patient teaching for urinary tract infections. So hugely important for nursing school. Big thing is if you have a vulva, you need to be wiping from front to back. We don't want to bring fecal bacteria up to the urethra, so wipe from front to back. Also, wear cotton underwear, no synthetic fabrics, because these are better at wicking moisture away and not trapping moisture, which bacteria love. Also, avoid bubble baths. Be sure to empty the bladder regularly, and be sure to void after vaginal penetrative intercourse. Very important patient teaching there. A few other things would be increase fluid intake. And cranberry juice can also help to decrease UTI symptoms.
All right. I hope that was a very helpful review for you. If it was, please like this video. Let me know in a comment. And if you have any other great ways to remember things, I would love to hear how you remember that, in the comments, and so would everybody else watching this. Be sure to subscribe to the channel. You want to be the first to know when the next video comes out. And our next video's going to talk about bladder scanners, how to use them, and we're also going to talk about urinary catheters. Super important stuff. I hope I see you there. Thanks so much, and happy studying.
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