Urinary Elimination 165v3j
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Module 34 Urinary Elimination
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Normal Structure and Function of the Urinary System
From Patton KT, Thibodeau GA: Anatomy and physiology, ed. 8, St. Louis, 2013, Mosby. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System (Cont.)
The urinary system is responsible for absorption of nutrients and fluids from the body’s intake. It controls the composition of blood by removing waste products known as urea and conserving useful substances.
Urea is produced when protein-rich foods are digested.
The urinary system helps to control blood pressure and plays a crucial role in acid–base balance. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System (Cont.)
Kidneys
Major excretory organs of the body Filter liquid waste from the blood Balance salts and electrolytes in the blood Regulate blood volume and pressure Produce erythropoietin for red blood cell (RBC) formation Synthesize vitamin D to help with calcium levels Maintains acid-base balance of extracellular fluid
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Urine Formation
Urine is formed by tiny filtering units called nephrons, which are the functional unit of the kidney.
Each nephron consists of the renal corpuscle and a small tube called the renal tubule. The renal corpuscle is comprised of a network of blood capillaries called the glomerulus, which is surrounded by Bowman capsule. The renal tubule is comprised of the proximal tubule, the loop of Henle, and the distal convoluted tubule.
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Urine Formation (Cont.)
Filtration initially occurs in the glomerulus as fluid moves across a membrane as the result of a pressure difference. Reabsorption occurs in the renal tubule as most of the filtrate moves back into the blood. At this point waste products, excess solutes, and small amounts of water are not reabsorbed but are secreted. As secretion takes place, urine is produced. Urea, water, and other waste substances form urine as they through the nephrons down the renal tubules. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System
Ureters
After exiting the kidneys, urine is carried to the bladder via narrow tubes called the ureters. The ureter wall muscles continually tighten and relax, forcing urine downward. If urine is retained in the kidney or backflows from the bladder toward the kidneys, the patient becomes susceptible to kidney infections.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System (Cont.)
Bladder and urethra
From the ureters, the urine flows slowly into the bladder, located below the umbilicus and above the symphysis pubis in the lower abdomen, for storage. The bladder walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. • Sphincter muscles at the base of the bladder help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. • The urethra transports urine from the bladder to outside the body for urine elimination and bladder emptying. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz! 1.
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse’s response is the: A. Bladder. B. Kidney. C. Nephron. D. Ureter.
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Urination
The innervation of the bladder signals when it is time to urinate and empty the bladder. This is referred to as urge, or urgency. The brain signals the bladder muscles to tighten and the sphincter muscles to relax, which squeezes urine out of the bladder through the urethra. When all the signals occur in the correct order, normal micturition, or urination, occurs.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Urine Characteristics
Urine can be dilute or very concentrated. Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi. Urine can be produced in small or large amounts.
The average adult es one to two quarts (960– 1920 mL) of urine per day, depending on the amount of fluids consumed, medications, medical conditions, and dietary intake (such as salt). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Altered Structure and Function
Altered elimination:
Urinary retention Loss of voluntary control of voiding
Factors affecting the structure or function of the urinary system
Psychosocial factors Food and fluid intake Surgical and diagnostic procedures Pathologic conditions (HTN, arteriosclerosis) Urinary tract infections Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study
Mrs. Vallero is a 65-year-old woman who has been in the hospital for 4 days with problems related to heart failure, fluid retention, and diabetes. She has a history of urinary retention secondary to neuropathy caused by her diabetes.
Mrs. Vallero’s indwelling urinary catheter was removed 2 days ago and subsequently was replaced yesterday at 6 A.M. because of her inability to urinate more than 100 mL at a time, being incontinent of small amounts of urine, complaints of urinary urgency, and lower abdominal pain.
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Abnormal Urination Patterns
Anuria: failure to produce or excrete 50 to 100 mL of urine in 24 hours Oliguria: reduced volume: 100 to 400 mL in 24 hours Polyuria: excessive production and excretion of urine Nocturia: excessive urination at night Dysuria: painful urination Hematuria: blood in the urine Urinary incontinence = the inability to control urination Urinary retention: Inability to empty the bladder fully Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Anuria
Anuria, the failure of the kidneys to excrete urine, results from any process that limits effective blood flow through the kidneys.
Diagnosis of anuria is made when a catheter is ed into the bladder and no urine is present. Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure. Acute anuria is life threatening and requires emergent investigation to determine the cause. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Anuria (Cont.)
Dialysis is a technique by which fluids and molecules through an artificial semipermeable membrane and are filtered via osmosis. During hemodialysis, the patient’s blood flows continually from the body through vascular catheters to the dialysis machine. Peritoneal dialysis is performed by instilling dialysis solution into the patient’s abdominal cavity through an external catheter. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Hemodialysis
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Oliguria
Oliguria is defined as reduced urine volume:
Less then 1mL/kg/h in an infant; Less than 0.5 mL/kg/h in children Less than 400 mL/day in adults
A symptom of acute or chronic renal failure Revealed by monitoring urinary output Classified
Prerenal from reduced blood flow to kidneys Renal from actual renal damage Postrenal failure from obstruction of urine flow Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Sandy notes that the urinary catheter was removed at 7 A.M. this morning, and the patient has no recorded urine output for the day. Mrs. Vallero verifies that she has only “dribbled” urine. While making rounds, Sandy talks with Mrs. Vallero, who says she is worried because “I thought this was all under control.” The health care provider is notified, and an order is obtained for an intermittent catheterization. The ed nurse on the day shift catheterizes Mrs. Vallero at 3 P.M. with a return of 600 mL of pale, clear yellow urine. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Safe Practice Alerts!
Measuring and recording intake and output (I&O) is an essential part of care for a majority of hospitalized patients, especially those experiencing fluid retention or excretion problems. Patients with acute or chronic renal failure may be placed on strict fluid intake restriction and have orders for the nurse to maintain strict I&O records.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Polyuria and Nocturia
Polyuria is an excessive volume of urine formed and excreted each day.
In adults, 2500 mL or more of urine per day.
Nocturia is excessive urination at night or awaking several times during the night to urinate.
Disrupts sleep cycle Associated with the use of medications such as diuretics, as well as urinary tract infections, congestive heart failure, cystitis (inflammation of the bladder), and diabetes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Dysuria and Hematuria
Dysuria = painful urination
Many causes are possible. Patients complain of burning. Delay in initiating voiding may be associated.
Hematuria = abnormal presence of RBCs in urine
Gross, visible, or microscopic hematuria may represent serious underlying disease. Urine color does not reflect degree of blood loss. Many causes are possible. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Incontinence
Urinary incontinence is the inability to control the age of urine. Stress incontinence is loss of urine control during activities that increase intraabdominal pressure, such as coughing, sneezing, laughing, or exercise. Urge incontinence involves a sudden strong urge to void, followed by rapid bladder contraction. Mixed incontinence = stress + urge incontinence Functional incontinence occurs despite the fact that the urinary tract is functioning effectively. Overflow incontinence is the inability to empty the bladder completely, resulting in a constant dribbling of urine or frequency in urination. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Retention
Urinary retention is the inability of the bladder to empty. It is caused by an obstruction in the urinary tract or by a neurologic disorder. Characteristics:
Difficulty starting a stream or emptying the bladder Weak urine flow Chronic or acute pain • Chronic = mild but constant discomfort • Acute = medical emergency
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Factors Affecting Urinary Elimination
Pathologic and surgical conditions Privacy issues and embarrassment Medications Food and fluid intake Ambulatory ability Muscle tone The cause of enuresis, the involuntary ing of urine, may be structural or pathologic, although it may be related to nonurinary problems such as constipation, stress, and illness. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Diversity Considerations Age: Loss of muscle tone in the bladder in older adult individuals contributes to incontinence and frequency. Nocturia is common as well. The bladder does not empty as efficiently in older people. Pregnancy: The growing fetus compromises bladder space and compresses the bladder, resulting in urinary frequency. Gender: Enlargement of the prostate in men age 40 and older may lead to urinary frequency, hesitancy and retention. Urinary tract infections are more prevalent in women because women have a shorter urethra and experience a decrease in muscle tone with age and childbirth. Culture: May cause patients not to seek treatment Disability: May lead to urinary incontinence or retention Morphology: Pressure can cause inadequate emptying and incontinence
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Factors Affecting Urinary Elimination
Developmental factors
Individual control of urination changes with age. Elderly patients are at risk for elimination problems secondary to age-related decreased function of the kidneys.
Psychosocial factors
Many people consider urination to be a private matter and have established behaviors or habits that are associated with voiding. Patients may voluntarily suppress the urge to void secondary to other circumstances. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz! 2.
A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. Large amounts of voided cloudy urine. B. Pain in the suprapubic region. C. Spasms and difficulty during urination. D. Small amounts of urine voided two to three times per hour.
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Factors Affecting Urinary Elimination
Food and fluid intake
Medications
Changes in a patient’s eating or drinking pattern can disrupt normal urination. Medication may alter the production, formation, concentration, clarity, and color of urine.
Muscle tone
Muscle tone plays a direct role in filling and emptying of the bladder.
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Case Study (Cont.)
As Sandy prepares to assess Mrs. Vallero again, she re that urinary problems are common in patients who have diabetes and in older adults. Age alone does not cause incontinence. She recalls that patients with urinary retention sometimes leak or “dribble” urine and are then misdiagnosed as incontinent. She knows that patients generally void at least every 6 to 8 hours, and that Mrs. Vallero’s recent catheterization, her decreased mobility, and her history of diabetes make her more prone to urinary retention, incontinence of small amounts of urine, and urinary tract infection (UTI).
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Factors Affecting Urinary Elimination (Cont.)
Surgical and diagnostic procedures
Surgical and diagnostic procedures alter the formation, concentration, color, and age of urine.
Pathologic conditions
Diseases of the kidneys reduce the production of urine. Heart and circulatory disorders diminish blood flow to the kidneys and affect urine production. Calculi may obstruct the ureter, blocking the flow of urine.
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Factors Affecting Urinary Elimination (Cont.)
Urinary tract infections (UTIs) are the result of bacteria in the urine. UTI is the single most common hospital-acquired infection.
Females are more vulnerable than males, with the rate of occurrence gradually increasing with age. People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and the elderly with bladder control loss. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Factors Affecting Urinary Elimination (Cont.)
A urinary diversion is a surgical procedure performed when bladder function is impaired due to trauma or disease involving the bladder, the distal ureters, and, rarely, the urethra.
From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.
Cutaneous urinary diversion
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Assessment (Cont.)
During the initial assessment while gathering subjective and objective data:
Consider the patient’s physical and mental abilities Prioritize immediate problems identified Address relief of symptoms prior to full assessment. Note signs of distress and patient orientation
Following a focused interview, including past and present health history, the nurse conducts a physical inspection of the abdomen.
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Health Assessment Questions (Cont.) Have you ever been diagnosed with kidney or bladder disease? Have you ever had surgery or trauma to the urinary system? Have you ever had a urinary tract or kidney infection? Do you have a family history of kidney disease or urinary problems? Do you have any physical problems that may affect the urinary tract, such as high blood pressure, diabetes, kidney stones, multiple sclerosis, Parkinson’s disease, spinal cord injury, or stroke? If so, have you noticed or experienced any problems with urinary retention? Have you experienced changes in your normal urination pattern? If so, have they caused you embarrassment or anxiety, and for how long? Are you able to control when you urinate? Do you ever have to get up at night to urinate? Do you have difficulty starting or stopping your flow of urine? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Health Assessment Questions (Cont.) Have you noticed difficulty initiating the stream of urine? Voiding in small amounts? Do you feel the need to void more frequently than in the past? Have you noticed any changes in the quality, quantity, color, or odor of the urine? If so, for how long? Do you take any vitamins or medications, such as antibiotics or diuretics, or eat any particular foods that might cause changes in the characteristics of your urine? Do you work in an environment or industry that exposes you to harsh chemicals? Do you experience pain, burning, itching, or other discomfort associated with urination or pain in the sides of your back or abdomen? If so, describe and rate the pain on a scale of 0 to 10. For female patients: How do you cleanse after urination or bowel movements?
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Assessment: Abdominal Examination
Explain the exam to the patient. Inspection Auscultation Percussion and palpation Courtesy Verathon Corporation, Bothell, Wash.
Bladder scan
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Case Study (Cont.)
Sandy knows that she will need to assess whether Mrs. Vallero feels the urge to urinate. She determines that no one has taken Mrs. Vallero to the bathroom recently. Sandy also needs to find out more about her patient’s urination patterns at home because Mrs. Vallero has verbalized anxiety about her present voiding patterns. Previous clinical experience has taught Sandy that palpation of the abdomen over a distended bladder causes some discomfort, and that the patient often experiences an urge to urinate. Mrs. Vallero grimaces when her abdomen is palpated and says she has a little dolor (pain). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Assessment of Urine
Color: Range is pale yellow to amber
Food Medication Pathologic conditions
Clarity: normally clear Odor: not very strong Amount: depends on fluid intake, dehydration, retention
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Urine Tests and Diagnostic Examinations Blood urea nitrogen and creatinine Urinalysis: specific gravity, pH, protein, glucose, ketones, microscopic analysis Culture and sensitivity 24-hour urine collection Ultrasound Kidney, ureter, and bladder x-ray Intravenous pyelography Computed tomography Cystoscopy Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests
Blood urea nitrogen (BUN) and creatinine
Blood levels of urea and creatinine are used to evaluate renal function. Urea is the end product of protein metabolism and is measured as BUN. • BUN is a measure of the urea level in the blood.
Creatinine is a waste product that is produced in the blood as a byproduct of muscle metabolism. • The patient with kidney damage has decreased urinary creatinine but increased serum levels.
BUN and creatinine are viewed in relationship to each other. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
Urinalysis
Assesses urine at a single point in time Screens for UTI, kidney disease, other conditions
Components
Specific gravity: balance of water and solutes pH: acid–base balance Protein: not normally in urine Glucose: normal urine has little to no glucose Ketones: indicates fat has been broken down for energy; not normally in the urine Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
Microscopic analysis
UTI suspicion
Urine is spun in a centrifuge and sediment settles at the bottom. The sediment is then spread on a slide and checked for RBCs or WBCs, casts, plugs, or crystals. Urine may be checked for nitrates. Nitrate levels elevate when bacteria are present.
Culture and sensitivity
Urine in the bladder is normally sterile; it does not contain bacteria or organisms. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
A 24-hour urine collection
Taken to determine the amount of creatinine cleared through the kidneys Also used to measure levels of protein, hormones, minerals, and other chemical compounds in urine Factors affecting accuracy • • • • •
Not collecting part of the output Continuing beyond 24 hours Spilling the specimen Inability to keep the specimen cool Ingestion of certain foods or medications.
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Diagnostic Examinations
Ultrasound of the bladder or kidneys
Assess the size, shape, and location of the kidneys Additional technology can monitor blood flow Safe for pregnant women and those with allergies to contrast media Factors that interfere with results • Severe obesity • Recent barium studies • Excessive flatus or intestinal gas
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Diagnostic Examinations (Cont.)
Kidney, ureter, and bladder x-ray (KUB)
A diagnostic x-ray centered on the iliac crest used to investigate gastrointestinal conditions such as a bowel obstruction and gallstones Can detect the presence of kidney stones. Also used to assess positioning of indwelling devices such as ureteric stents
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Diagnostic Examinations (Cont.)
Intravenous pyelogram (IVP)
X-ray of the kidneys, bladder, ureters, and urethra • Images show the size, shape, and position of the urinary tract. • Commonly performed to identify kidney stones, tumors, or infection; to measure the size of a tumor of the urinary tract; and to look for urinary tract damage after injury.
Computed tomography (CT) of the kidneys, ureters, and bladder • Used to diagnose kidney stones, bladder stones, or blockage of the urinary tract • Contrast media may be used during the procedure to look for blockages, growths, infections, or other diseases. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Diagnostic Examinations (Cont.)
Cystoscopy = examination of the bladder and urethra via a cystoscope inserted into the urethra and advanced into the bladder
Permits visualization of areas that do not show up well on x-ray Performed to determine the cause of hematuria, dysuria, incontinence, frequency, urgency, or retention Also used in the diagnosis of conditions that cause blockage of the urethra Tissue biopsy can be performed.
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Nursing Diagnosis Impaired urinary elimination Urge urinary incontinence Ineffective coping Pain
Stress urinary incontinence Reflex urinary incontinence Toileting self-care deficit Disturbed body image
Functional urinary incontinence Risk for impaired skin integrity Risk for infection
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Urinary retention
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Planning NANDA-I Nursing Diagnosis with nursing diagnosis statement Impaired urinary elimination related to microorganisms in the urinary tract as evidenced by urgency, frequency and reports of burning with urination.
Nursing Outcomes Classification (NOC) Urinary Elimination (0503) Absence of urinary frequency (050331)
Nursing Interventions Classification (NIC) Urinary Elimination Management (0590) Instruct patient to monitor for signs and symptoms of urinary tract infection.
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Planning (Cont.) COLLABORATION AND DELEGATION • UAP often aid patients in toileting. The nurse must communicate assessment parameters, such as measuring the amount of urine, noting its color, and determining the frequency. The nurse must stress to the UAP the necessity of documenting voiding patterns. • Nurse continence specialists may need to be consulted to teach pelvic floor exercises. • Physical therapists can design a plan to increase overall muscle strength. • The family may need to alter the home environment to accommodate the patient’s elimination needs, depending on physical limitations.
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Implementation and Evaluation (Cont.)
The focus of each goal is directly related to the identified nursing diagnosis, which in turn determines what interventions are most appropriate for each patient. The nurse must focus on activities that will help the patient with compromised urinary elimination return to the normal state of function or to adapt to changes in the state of function. Ongoing assessment and follow-up are needed to assure quality in the care provided and to determine need for further nursing interventions. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Patient Education and Health Literacy
Instruct patients and families on safe transfer techniques for individuals with limited mobility needing voiding assistance. Instruct patients to respond promptly to urge to avoid urinary retention and reduce infection risk. Emphasize the importance of maintaining fluid intake to help flush the urinary system. Instruct patients to promptly report pain or burning on urination; changes in urine color, odor, or clarity; or changes in voiding patterns. Teach patients the importance of taking medications as prescribed. Instruct patients and families in desired or adverse side effects that may influence the patient’s urinary elimination pattern. Stress the importance of maintaining fluid intake or restrictions based on the medication.
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Patient Education and Health Literacy (Cont.)
Reinforce with female patients proper aseptic technique, including washing front to back to maintain cleanliness. Remind male patients to retract foreskin, if present, to thoroughly wash the urinary meatus. Be sure to stress the importance of drying the area thoroughly to prevent skin breakdown or irritation. Teach proper care of indwelling catheters and the perineal area, including emptying and cleaning the device, maintaining a closed system, and bladder irrigation, or flushing, if necessary. Arrange for a wound ostomy continence nurse (WOCN) to teach patients with a urinary diversion appropriate care for the stoma, drainage devices, and skin.
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Home Care Considerations • • •
• • •
Assessing the home for safety issues related to urinary elimination is important. The patient must be able to easily access toilet facilities. Adequate lighting should be ensured. Necessary assistive and safety equipment, such as grab bars and raised toilet seats, should be in place in the home prior to discharge, as needed. Bedpans and a bedside commode, if warranted, should be in the home ahead of time. Supplies necessary for catheterization and catheter care, for urinary diversions, and for incontinence care should be purchased. Appropriate referrals to home health or social services should be made prior to discharge. Services such as home health aides for assistance with ADLs should be confirmed. Community resources such as the United Ostomy Association and National Association for Continence should be identified as a resource for patients and their families. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Safe Practice Alert!
The home environment should be assessed for factors that may interfere with toileting. Distance to the toilet, physical layout of the toileting facilities, clutter, stairways, rugs, and inadequate lighting may put ambulatory patients at safety risk.
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Promoting Normal Urinary Patterns in a Health Care Facility
In the health care facility, there are often conflicts with a person’s normal routine. Proper integration of the patient’s habits into daily care will aid in preventing elimination issues. Safe Practice Alert!
Medications such as diuretics may cause frequency or urgency, potentially compromising patient safety risk. Instruct patients who are on falls precautions to ask for assistance prior to ambulation for toileting. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Bedpan and Urinal
The urinal is used by a patient while standing, sitting, or lying down. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Assisting a patient with a urinal
Background • Routine urination and complete emptying of the bladder prevents many complications. • Encourage routine use of the urinal for male patients who are unable to ambulate to the bathroom.
Documentation concerns • Document the quantity, color, quality, and odor of the urine. • Note the stream characteristics. • Monitor frequency of urination.
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Safe Practice Alerts!
Urine color, clarity, and odor should be assessed prior to disposal. Urine quantity must be measured before it is discarded to ensure accurate I&O records. Dehydration can pose a risk for patients trying to control incontinence problems by avoiding adequate fluid consumption. Dehydration may affect the patient’s mental status, further contributing to risk. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Bedside Commode
A bedside commode is a chair with a toilet seat top that has a container underneath to collect urine or stool for the patient who is unable to get to the bathroom. The container is removed for emptying and cleaning. Use of a bedside commode is more conducive to elimination than the bedpan. A patient may need to use a bedside commode if weak or unsteady, if the patient is at risk for falling, or becomes short of breath when ambulating. It should not be used for the patient who is unable to stand, who is maintained on strict bed rest, or who is at safety risk in an upright position. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Promoting Normal Urinary Patterns in a Health Care Facility (Cont.)
Privacy
Toileting schedule
If possible, the patient should be given time and privacy to void. Determining the patient’s toileting pattern may assist the person with urinary elimination. The patient should be encouraged to void at regular intervals whether urge is felt or not.
Fluid intake
Increasing fluid intake will increase urine production in the patient without renal or cardiac dysfunction. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Findings:
Patient is able to palpate bladder, indicating bladder distention. During palpation, patient states she has the sensation of bladder fullness. Patient complains of dribbling frequently and being unable to urinate.
What are the specific assessment activities that produced these findings? What other assessment questions should be asked?
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Monitoring Intake & Output (I&O)
Intake includes all food and oral fluids as well as tube feedings and intravenous fluids.
Oral fluids are recorded in milliliters (mL) according to the size of the container from which they are consumed. Ice chips are documented as approximately one half of their volume. The volume of tube feedings and intravenous therapies (both maintenance and piggy back) are noted on the can or bag in which they are supplied.
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Monitoring Intake & Output (I&O) (Cont.)
Output is measured by collecting it in bed pans, urinals, urinary catheters, drains, ostomy bags, nasogastric tubes, or collection devices commonly referred to as urine “hats” placed in the front of a toilet or bedside commode.
From Birchenall JM, Streight E: Mosby ’ s textbook for home care aide, ed. 3, St. Louis, 2013, Mosby.
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Intake and Output Calculation POSITIVE BALANCE Intake Output Oral fluid = 700 mL Urine = 940 mL IV fluid =1250 mL Vomitus = 50 mL 8-hour Intake Total = 8-hour Output Total = 1950 mL 990 mL I&O Balance = +960 (= 1950 - 990)
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Intake and Output Calculation (Cont.) NEGATIVE BALANCE Intake Output Oral fluid = 100 mL Urine = 640 mL Tube feeding = 480 mL Hemovac drainage = 400 mL 8-hour Intake Total = 580 8-hour output total = mL 1040 mL I&O Balance = −460 (= 580 - 1040)
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Quick Quiz! 3. A young girl is having problems urinating postoperatively. You that children may have trouble voiding: A. In bathrooms other than their own. B. In a urinal. C. While lying in bed. D. In the presence of a person other than their parents.
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Kegel Exercises
Kegel exercises help keep the female pelvic floor toned, which reduces the risk of incontinence. If performed correctly and regularly, Kegel exercises have been shown to strengthen the pelvic floor muscles which the uterus, bladder, and bowel.
Improvement is normally seen in approximately 8 to 10 weeks.
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Nursing Care Guideline
Kegel exercise techniques
Background • Kegel exercises are also known as pelvic floor exercises. • They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence. • Exercises can be done while sitting or standing. Documentation concerns • Document that patient education was provided.
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Prevention of UTIs
Prevention is key! Instruct patients about ways to prevent infection or recurrence:
Avoid wearing tight-fitting clothing. Drink at least eight 8-ounce glasses of water each day Urinate when the urge is felt. Women and girls should wipe “front to back.” Urinate after sexual intercourse. Showers are preferred instead of baths. Good perineal hygiene is essential. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Prevention of UTIs (Cont.)
Treatment for a UTI requires antibiotics
Symptom relief may be quick: 1-2 days Kidney infections may take weeks to resolve Severely ill people may need hospitalization with IV antibiotics
~80% of UTIs are the result of catheterization
Avoiding the use of indwelling catheters is a primary method for UTI prevention.
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Case Study (Cont.)
Nursing diagnosis: Urinary retention related to weakened detrusor muscle and recent removal of indwelling urinary catheter Goal: Mrs. Vallero will have normal micturition within 1 month. What expected outcomes would you establish to measure goal achievement?
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Urinary Catheterization
Urinary catheterization is most often performed through introduction of a catheter into the patient’s urethra. Straight, Foley, triple-lumen, and Coudé catheters are used for urinary catheterization.
Modifi ed from Wein AJ: Campbell-Walsh urology, ed. 9, Philadelphia, 2007, Saunders.
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Urinary Catheterization (Cont.)
Most indwelling catheters (commonly referred to as Foley catheters) have two lumens: one for filling a balloon at the tip of the catheter to “anchor” it in place and the other for draining urine. Coudé catheters are a special type of double-lumen, indwelling catheter that are slightly stiff and bent at the end allowing the catheter to more easily through a partially constricted urethra. Triple-lumen catheters are used for bladder irrigation. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Skill 41-1: Urinary Catheterization: Insertion and Care PURPOSE: Urinary Catheters Are Used To: Assess bladder function Accurately monitor urinary output Obtain urine specimens Manage urinary incontinence Irrigate the bladder Relieve bladder distention and discomfort Manage urinary Instill medications into the retention bladder Allow for healing after surgical procedures
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Skill 41-1: Urinary Catheterization: Insertion and Care
Collaboration and delegation
Inserting a straight catheter may be delegated to UAP) without a nurse’s assistance: • Following assessment of the patient • Depending upon the state and institution’s policies and procedures • Provided the UAP has received the appropriate specialized training
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Skill 41-1: Urinary Catheterization: Insertion and Care
Collaboration and delegation
UAP should report any of the following to the nurse: • Patient reports of pain before, during, or after the procedure; • Sores, wounds, irritations, or lesions noted; and/or • Difficulties encountered while performing the procedure.
UAPs should be instructed in: • Sterile technique, • Appropriate procedure and timing, and • Required documentation.
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Skill 41-1: Urinary Catheterization: Insertion and Care
Evidence-based practice
To prevent catheter-associated urinary tract infections, “insert catheters only for appropriate indications, and leave in place only as long as needed. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.” Anchoring of the catheter is imperative, not only to prevent inadvertent dislodgement, but also to prevent pressure ulcers. Intermittent catheterizations have been shown to have a lower incidence of UTIs then do indwelling catheters in acute-care facilities, even when ing for the same time frame of catheter necessity.
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Case Study (Cont.)
Interventions for urinary retention care include:
Assist with toileting every 2 to 3 hours while awake. Instruct the patient/family to record urinary output as appropriate. Have Mrs. Vallero take a warm bath if unable to urinate.
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Skill 41-2: Closed Bladder Irrigation
Purpose: Bladder irrigation is performed to:
Maintain patency of catheters, As a postoperative procedure for genitourinary surgeries, and Decrease genitourinary complications (such as infections).
Evidence-based practice
“Unless obstruction is anticipated (e.g., as might occur with bleeding after prostate or bladder surgery), bladder irrigation is not recommended. Routine irrigation of the bladder with antimicrobials is not recommended.” Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Skill 41-2: Closed Bladder Irrigation
Collaboration and Delegation
Bladder irrigation may not be delegated to UAP without a nurse’s assistance. UAP helping to care for the patient should report any of the following to the nurse: • Patient complaints of pain before or after the procedure; • Clots noted in output; • Change in color, odor, consistency, or amount (COCA) of output; • Sores, wounds, irritations, or lesions noted; • Fever or other changes in vital signs.
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Case Study (Cont.)
Sandy talks with Mrs. Vallero the next evening. The patient’s care plan incorporates scheduled voiding and oral fluids. She palpates Mrs.Vallero’s bladder and then assists her to the toilet. After making sure she is comfortable and leaving the call light in place, Sandy leaves Mrs. Vallero to void on her own. She returns to measure Mrs. Vallero’s urinary output and evaluates for bladder residual using an ultrasound bladder scan. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Discontinuing an Indwelling Catheter
Indwelling urinary catheters should only be placed when indicated and should be removed as soon as possible. Catheter use is appropriate:
For relief of acute urinary obstruction or retention During some surgical procedures To accurately measure urine in critically ill patients During perineal or sacral wound healing in incontinent patients When a patient is immobilized for an extended period of time For patient comfort at end of life Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Discontinuing an indwelling catheter
Background • Indwelling catheters are a primary source of urinary tract infections (UTIs) and should be removed as soon as possible. • The Centers for Disease Control and Prevention (CDC) has issued guidelines for insertion, use, and removal to aid in decreasing catheter-associated UTIs. • The patient may experience burning and difficulty voiding, as well as frequency or retention, after removal.
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Nursing Care Guideline (Cont.)
Discontinuing an Indwelling Catheter (Cont.)
Documentation concerns • Record urinary output. • Document any difficulties with performing the procedure, as well as the patient’s response to the procedure. • Note any patient education that was done. • Record the findings of the urinary assessment after catheter removal, including
The quantity of urine, and frequency of urination, and The color, odor, consistency, and character of the urine.
• Include any difficulty encountered by the patient with urinary retention and/or bladder distention.
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Nursing Care Guideline (Cont.)
Discontinuing an Indwelling Catheter (Cont.)
Evidence-based practice • Postoperative patients should have an indwelling catheter removed within 24 hours of surgery unless there are other appropriate reasons for the catheter to remain in place. • Some studies have been done regarding whether or not to clamp the catheter prior to removing it. The evidence leans slightly in the direction that it is better to leave the catheter unclamped so the urine is flowing freely as the catheter is removed. Additional studies have shown that there have been fewer cases of bacteriuria when this practice is applied.
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Routine Catheter Care
Catheters should be inserted using aseptic technique and sterile equipment, as recommended by the CDC. Once the catheter is placed, the urethral meatus should be cleansed with soap and water once or twice daily. Preconnected closed drainage urinary catheterization systems should be used to reduce risk of interruption of the system by staff or patient’s family. Catheters should be changed if debris or encrustation of the catheter is noted. Catheter bags should be emptied when two thirds full.
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Evidence-Based Practie
Urinary catheter infection prevention
It is imperative that catheter bags be kept below the level of the bladder at all times to prevent reflux of urine into the bladder, which may lead to catheteracquired urinary tract infection (CAUTI).
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Suprapubic Catheters
Suprapubic catheters are inserted directly into the bladder just above the pubic bone. Surgical placement of a suprapubic catheter may be undertaken if urethral catheterization is either contraindicated or unsuccessful. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Condom Catheters
Condom catheter use is less likely to lead to bacteriuria, UTI, and death, than use of indwelling catheters in patients who retain urine. However, condom catheters are not without risk: Skin necrosis, penile strangulation and urethrocutaneous fistulas, dermatitis, skin erosion, pain, and localized infection have been reported. Male patients report that condom catheters are more comfortable and less painful than indwelling catheters. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Applying a condom catheter
Background • A condom catheter (also known as an external catheter or a Texas catheter) is used as an incontinence solution for the male patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline (Cont.)
Applying a condom catheter (Cont.)
Documentation concerns • Record any difficulties encountered with placing the catheter. • Document urine output and the quantity, color, and odor of the urine. • Document neurovascular monitoring of the penis.
Evidence-based practice • “The use of condom catheters is less likely to lead to bacteriuria, symptomatic UTI, or death than the use of indwelling catheters” (Saint et al, 2006) • It is important to note that, without proper care and routine assessment, condom catheters can cause skin breakdown and other complications that can lead to external infections Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Perineal Care
Skin care is important in patients with urinary elimination issues, including those with indwelling catheters to help prevent infection. Frequent perineal care is necessary, although use of harsh soaps, bubble baths, powder, or sprays, which can irritate the urethra, leading to inflammation and infection, should be avoided. The perineal area should be cleansed with soap and water or no-rinse cleansers frequently and dried thoroughly. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Diversion Care
Patients should be encouraged to provide their own urinary diversion care, as much as possible. Individuals who have recently undergone diversion surgery will require a demonstration and patient education on how best to manage and care for their particular type of urinary diversion. Participation in a group of others with urinary diversions may be helpful in addressing individual concerns. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline (Cont.)
Urinary diversion care
Background: • Various disease processes or disorders, such as cancers, spinal cord injury, or renal calculi, may necessitate the ureters to be diverted externally from the meatus of the bladder to the abdominal wall.
Documentation concerns • Document patient urinary I&O. • Note stoma condition and skin appearance. • Record color, odor, consistency, and amount of urine.
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Nursing Care Guideline (Cont.) TYPES OF URINARY DIVERSIONS The ureters are connected to the The small bowel resection is resected small bowel. brought to the abdominal wall. An ileal neobladder is the most A stoma is created in the common continent urinary abdominal wall. diversion The patient catheterizes the Urine drains through the stoma stoma to drain the urine, if into a collection bag/device. necessary. A section of intestine is used to A stoma is created in the create a pouch to hold urine. abdominal wall. An ileal conduit is the most common noncontinent urinary diversion. A section of small bowel is resected.
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Obtaining Urine Specimens
The nurse is responsible for collecting urine specimens.
Specimens may be collected for routine urinalysis via normal voiding into a specimen cup or into a clean urinal or bedpan. For culture and sensitivity testing, urine is collected by the clean catch, or midstream, method, using a sterile specimen cup. Specimens can also be obtained by performing a straight catheterization using sterile technique or by removal of a specimen from the tubing of an indwelling catheter or urinary diversion collection bag. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Ask Mrs. Vallero about her urge to void, sensation of bladder fullness, and dribbling episodes. Have Mrs. Vallero keep a log of her pattern of elimination, including urine output volumes with each voiding, during the 1-month period. Ask Mrs. Vallero if she continues to have lower abdominal pain.
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Evaluation
Sharing evaluation findings with patients helps them recognize goal achievement and move closer to healthy urinary elimination patterns regardless of previous challenges. Prevention of kidney disease, urinary tract infections, and secondary complications such as skin breakdown related to incontinence is ongoing, whether the patient is in a health care facility or at home.
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Case Study (Cont.)
Mrs. Vallero is concerned about regaining her urinary function. Sandy develops the following outcome for her: At the end of the teaching session, Mrs. Vallero will be able to describe approaches to promote normal urinary elimination habits. What teaching strategies would you put into the plan? What evaluation strategies would you use?
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Normal Structure and Function of the Urinary System
From Patton KT, Thibodeau GA: Anatomy and physiology, ed. 8, St. Louis, 2013, Mosby. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System (Cont.)
The urinary system is responsible for absorption of nutrients and fluids from the body’s intake. It controls the composition of blood by removing waste products known as urea and conserving useful substances.
Urea is produced when protein-rich foods are digested.
The urinary system helps to control blood pressure and plays a crucial role in acid–base balance. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System (Cont.)
Kidneys
Major excretory organs of the body Filter liquid waste from the blood Balance salts and electrolytes in the blood Regulate blood volume and pressure Produce erythropoietin for red blood cell (RBC) formation Synthesize vitamin D to help with calcium levels Maintains acid-base balance of extracellular fluid
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Urine Formation
Urine is formed by tiny filtering units called nephrons, which are the functional unit of the kidney.
Each nephron consists of the renal corpuscle and a small tube called the renal tubule. The renal corpuscle is comprised of a network of blood capillaries called the glomerulus, which is surrounded by Bowman capsule. The renal tubule is comprised of the proximal tubule, the loop of Henle, and the distal convoluted tubule.
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Urine Formation (Cont.)
Filtration initially occurs in the glomerulus as fluid moves across a membrane as the result of a pressure difference. Reabsorption occurs in the renal tubule as most of the filtrate moves back into the blood. At this point waste products, excess solutes, and small amounts of water are not reabsorbed but are secreted. As secretion takes place, urine is produced. Urea, water, and other waste substances form urine as they through the nephrons down the renal tubules. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Normal Structure and Function of the Urinary System
Ureters
After exiting the kidneys, urine is carried to the bladder via narrow tubes called the ureters. The ureter wall muscles continually tighten and relax, forcing urine downward. If urine is retained in the kidney or backflows from the bladder toward the kidneys, the patient becomes susceptible to kidney infections.
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Normal Structure and Function of the Urinary System (Cont.)
Bladder and urethra
From the ureters, the urine flows slowly into the bladder, located below the umbilicus and above the symphysis pubis in the lower abdomen, for storage. The bladder walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. • Sphincter muscles at the base of the bladder help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. • The urethra transports urine from the bladder to outside the body for urine elimination and bladder emptying. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz! 1.
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse’s response is the: A. Bladder. B. Kidney. C. Nephron. D. Ureter.
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Urination
The innervation of the bladder signals when it is time to urinate and empty the bladder. This is referred to as urge, or urgency. The brain signals the bladder muscles to tighten and the sphincter muscles to relax, which squeezes urine out of the bladder through the urethra. When all the signals occur in the correct order, normal micturition, or urination, occurs.
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Normal Urine Characteristics
Urine can be dilute or very concentrated. Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi. Urine can be produced in small or large amounts.
The average adult es one to two quarts (960– 1920 mL) of urine per day, depending on the amount of fluids consumed, medications, medical conditions, and dietary intake (such as salt). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Altered Structure and Function
Altered elimination:
Urinary retention Loss of voluntary control of voiding
Factors affecting the structure or function of the urinary system
Psychosocial factors Food and fluid intake Surgical and diagnostic procedures Pathologic conditions (HTN, arteriosclerosis) Urinary tract infections Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study
Mrs. Vallero is a 65-year-old woman who has been in the hospital for 4 days with problems related to heart failure, fluid retention, and diabetes. She has a history of urinary retention secondary to neuropathy caused by her diabetes.
Mrs. Vallero’s indwelling urinary catheter was removed 2 days ago and subsequently was replaced yesterday at 6 A.M. because of her inability to urinate more than 100 mL at a time, being incontinent of small amounts of urine, complaints of urinary urgency, and lower abdominal pain.
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Abnormal Urination Patterns
Anuria: failure to produce or excrete 50 to 100 mL of urine in 24 hours Oliguria: reduced volume: 100 to 400 mL in 24 hours Polyuria: excessive production and excretion of urine Nocturia: excessive urination at night Dysuria: painful urination Hematuria: blood in the urine Urinary incontinence = the inability to control urination Urinary retention: Inability to empty the bladder fully Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Anuria
Anuria, the failure of the kidneys to excrete urine, results from any process that limits effective blood flow through the kidneys.
Diagnosis of anuria is made when a catheter is ed into the bladder and no urine is present. Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure. Acute anuria is life threatening and requires emergent investigation to determine the cause. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Anuria (Cont.)
Dialysis is a technique by which fluids and molecules through an artificial semipermeable membrane and are filtered via osmosis. During hemodialysis, the patient’s blood flows continually from the body through vascular catheters to the dialysis machine. Peritoneal dialysis is performed by instilling dialysis solution into the patient’s abdominal cavity through an external catheter. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Hemodialysis
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Oliguria
Oliguria is defined as reduced urine volume:
Less then 1mL/kg/h in an infant; Less than 0.5 mL/kg/h in children Less than 400 mL/day in adults
A symptom of acute or chronic renal failure Revealed by monitoring urinary output Classified
Prerenal from reduced blood flow to kidneys Renal from actual renal damage Postrenal failure from obstruction of urine flow Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Sandy notes that the urinary catheter was removed at 7 A.M. this morning, and the patient has no recorded urine output for the day. Mrs. Vallero verifies that she has only “dribbled” urine. While making rounds, Sandy talks with Mrs. Vallero, who says she is worried because “I thought this was all under control.” The health care provider is notified, and an order is obtained for an intermittent catheterization. The ed nurse on the day shift catheterizes Mrs. Vallero at 3 P.M. with a return of 600 mL of pale, clear yellow urine. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Safe Practice Alerts!
Measuring and recording intake and output (I&O) is an essential part of care for a majority of hospitalized patients, especially those experiencing fluid retention or excretion problems. Patients with acute or chronic renal failure may be placed on strict fluid intake restriction and have orders for the nurse to maintain strict I&O records.
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Polyuria and Nocturia
Polyuria is an excessive volume of urine formed and excreted each day.
In adults, 2500 mL or more of urine per day.
Nocturia is excessive urination at night or awaking several times during the night to urinate.
Disrupts sleep cycle Associated with the use of medications such as diuretics, as well as urinary tract infections, congestive heart failure, cystitis (inflammation of the bladder), and diabetes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Dysuria and Hematuria
Dysuria = painful urination
Many causes are possible. Patients complain of burning. Delay in initiating voiding may be associated.
Hematuria = abnormal presence of RBCs in urine
Gross, visible, or microscopic hematuria may represent serious underlying disease. Urine color does not reflect degree of blood loss. Many causes are possible. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Incontinence
Urinary incontinence is the inability to control the age of urine. Stress incontinence is loss of urine control during activities that increase intraabdominal pressure, such as coughing, sneezing, laughing, or exercise. Urge incontinence involves a sudden strong urge to void, followed by rapid bladder contraction. Mixed incontinence = stress + urge incontinence Functional incontinence occurs despite the fact that the urinary tract is functioning effectively. Overflow incontinence is the inability to empty the bladder completely, resulting in a constant dribbling of urine or frequency in urination. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Retention
Urinary retention is the inability of the bladder to empty. It is caused by an obstruction in the urinary tract or by a neurologic disorder. Characteristics:
Difficulty starting a stream or emptying the bladder Weak urine flow Chronic or acute pain • Chronic = mild but constant discomfort • Acute = medical emergency
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Factors Affecting Urinary Elimination
Pathologic and surgical conditions Privacy issues and embarrassment Medications Food and fluid intake Ambulatory ability Muscle tone The cause of enuresis, the involuntary ing of urine, may be structural or pathologic, although it may be related to nonurinary problems such as constipation, stress, and illness. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Diversity Considerations Age: Loss of muscle tone in the bladder in older adult individuals contributes to incontinence and frequency. Nocturia is common as well. The bladder does not empty as efficiently in older people. Pregnancy: The growing fetus compromises bladder space and compresses the bladder, resulting in urinary frequency. Gender: Enlargement of the prostate in men age 40 and older may lead to urinary frequency, hesitancy and retention. Urinary tract infections are more prevalent in women because women have a shorter urethra and experience a decrease in muscle tone with age and childbirth. Culture: May cause patients not to seek treatment Disability: May lead to urinary incontinence or retention Morphology: Pressure can cause inadequate emptying and incontinence
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Factors Affecting Urinary Elimination
Developmental factors
Individual control of urination changes with age. Elderly patients are at risk for elimination problems secondary to age-related decreased function of the kidneys.
Psychosocial factors
Many people consider urination to be a private matter and have established behaviors or habits that are associated with voiding. Patients may voluntarily suppress the urge to void secondary to other circumstances. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz! 2.
A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. Large amounts of voided cloudy urine. B. Pain in the suprapubic region. C. Spasms and difficulty during urination. D. Small amounts of urine voided two to three times per hour.
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Factors Affecting Urinary Elimination
Food and fluid intake
Medications
Changes in a patient’s eating or drinking pattern can disrupt normal urination. Medication may alter the production, formation, concentration, clarity, and color of urine.
Muscle tone
Muscle tone plays a direct role in filling and emptying of the bladder.
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Case Study (Cont.)
As Sandy prepares to assess Mrs. Vallero again, she re that urinary problems are common in patients who have diabetes and in older adults. Age alone does not cause incontinence. She recalls that patients with urinary retention sometimes leak or “dribble” urine and are then misdiagnosed as incontinent. She knows that patients generally void at least every 6 to 8 hours, and that Mrs. Vallero’s recent catheterization, her decreased mobility, and her history of diabetes make her more prone to urinary retention, incontinence of small amounts of urine, and urinary tract infection (UTI).
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Factors Affecting Urinary Elimination (Cont.)
Surgical and diagnostic procedures
Surgical and diagnostic procedures alter the formation, concentration, color, and age of urine.
Pathologic conditions
Diseases of the kidneys reduce the production of urine. Heart and circulatory disorders diminish blood flow to the kidneys and affect urine production. Calculi may obstruct the ureter, blocking the flow of urine.
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Factors Affecting Urinary Elimination (Cont.)
Urinary tract infections (UTIs) are the result of bacteria in the urine. UTI is the single most common hospital-acquired infection.
Females are more vulnerable than males, with the rate of occurrence gradually increasing with age. People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and the elderly with bladder control loss. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Factors Affecting Urinary Elimination (Cont.)
A urinary diversion is a surgical procedure performed when bladder function is impaired due to trauma or disease involving the bladder, the distal ureters, and, rarely, the urethra.
From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.
Cutaneous urinary diversion
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Assessment (Cont.)
During the initial assessment while gathering subjective and objective data:
Consider the patient’s physical and mental abilities Prioritize immediate problems identified Address relief of symptoms prior to full assessment. Note signs of distress and patient orientation
Following a focused interview, including past and present health history, the nurse conducts a physical inspection of the abdomen.
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Health Assessment Questions (Cont.) Have you ever been diagnosed with kidney or bladder disease? Have you ever had surgery or trauma to the urinary system? Have you ever had a urinary tract or kidney infection? Do you have a family history of kidney disease or urinary problems? Do you have any physical problems that may affect the urinary tract, such as high blood pressure, diabetes, kidney stones, multiple sclerosis, Parkinson’s disease, spinal cord injury, or stroke? If so, have you noticed or experienced any problems with urinary retention? Have you experienced changes in your normal urination pattern? If so, have they caused you embarrassment or anxiety, and for how long? Are you able to control when you urinate? Do you ever have to get up at night to urinate? Do you have difficulty starting or stopping your flow of urine? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Health Assessment Questions (Cont.) Have you noticed difficulty initiating the stream of urine? Voiding in small amounts? Do you feel the need to void more frequently than in the past? Have you noticed any changes in the quality, quantity, color, or odor of the urine? If so, for how long? Do you take any vitamins or medications, such as antibiotics or diuretics, or eat any particular foods that might cause changes in the characteristics of your urine? Do you work in an environment or industry that exposes you to harsh chemicals? Do you experience pain, burning, itching, or other discomfort associated with urination or pain in the sides of your back or abdomen? If so, describe and rate the pain on a scale of 0 to 10. For female patients: How do you cleanse after urination or bowel movements?
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Assessment: Abdominal Examination
Explain the exam to the patient. Inspection Auscultation Percussion and palpation Courtesy Verathon Corporation, Bothell, Wash.
Bladder scan
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Case Study (Cont.)
Sandy knows that she will need to assess whether Mrs. Vallero feels the urge to urinate. She determines that no one has taken Mrs. Vallero to the bathroom recently. Sandy also needs to find out more about her patient’s urination patterns at home because Mrs. Vallero has verbalized anxiety about her present voiding patterns. Previous clinical experience has taught Sandy that palpation of the abdomen over a distended bladder causes some discomfort, and that the patient often experiences an urge to urinate. Mrs. Vallero grimaces when her abdomen is palpated and says she has a little dolor (pain). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Assessment of Urine
Color: Range is pale yellow to amber
Food Medication Pathologic conditions
Clarity: normally clear Odor: not very strong Amount: depends on fluid intake, dehydration, retention
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Urine Tests and Diagnostic Examinations Blood urea nitrogen and creatinine Urinalysis: specific gravity, pH, protein, glucose, ketones, microscopic analysis Culture and sensitivity 24-hour urine collection Ultrasound Kidney, ureter, and bladder x-ray Intravenous pyelography Computed tomography Cystoscopy Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests
Blood urea nitrogen (BUN) and creatinine
Blood levels of urea and creatinine are used to evaluate renal function. Urea is the end product of protein metabolism and is measured as BUN. • BUN is a measure of the urea level in the blood.
Creatinine is a waste product that is produced in the blood as a byproduct of muscle metabolism. • The patient with kidney damage has decreased urinary creatinine but increased serum levels.
BUN and creatinine are viewed in relationship to each other. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
Urinalysis
Assesses urine at a single point in time Screens for UTI, kidney disease, other conditions
Components
Specific gravity: balance of water and solutes pH: acid–base balance Protein: not normally in urine Glucose: normal urine has little to no glucose Ketones: indicates fat has been broken down for energy; not normally in the urine Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
Microscopic analysis
UTI suspicion
Urine is spun in a centrifuge and sediment settles at the bottom. The sediment is then spread on a slide and checked for RBCs or WBCs, casts, plugs, or crystals. Urine may be checked for nitrates. Nitrate levels elevate when bacteria are present.
Culture and sensitivity
Urine in the bladder is normally sterile; it does not contain bacteria or organisms. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Laboratory Tests (Cont.)
A 24-hour urine collection
Taken to determine the amount of creatinine cleared through the kidneys Also used to measure levels of protein, hormones, minerals, and other chemical compounds in urine Factors affecting accuracy • • • • •
Not collecting part of the output Continuing beyond 24 hours Spilling the specimen Inability to keep the specimen cool Ingestion of certain foods or medications.
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Diagnostic Examinations
Ultrasound of the bladder or kidneys
Assess the size, shape, and location of the kidneys Additional technology can monitor blood flow Safe for pregnant women and those with allergies to contrast media Factors that interfere with results • Severe obesity • Recent barium studies • Excessive flatus or intestinal gas
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Diagnostic Examinations (Cont.)
Kidney, ureter, and bladder x-ray (KUB)
A diagnostic x-ray centered on the iliac crest used to investigate gastrointestinal conditions such as a bowel obstruction and gallstones Can detect the presence of kidney stones. Also used to assess positioning of indwelling devices such as ureteric stents
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Diagnostic Examinations (Cont.)
Intravenous pyelogram (IVP)
X-ray of the kidneys, bladder, ureters, and urethra • Images show the size, shape, and position of the urinary tract. • Commonly performed to identify kidney stones, tumors, or infection; to measure the size of a tumor of the urinary tract; and to look for urinary tract damage after injury.
Computed tomography (CT) of the kidneys, ureters, and bladder • Used to diagnose kidney stones, bladder stones, or blockage of the urinary tract • Contrast media may be used during the procedure to look for blockages, growths, infections, or other diseases. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Diagnostic Examinations (Cont.)
Cystoscopy = examination of the bladder and urethra via a cystoscope inserted into the urethra and advanced into the bladder
Permits visualization of areas that do not show up well on x-ray Performed to determine the cause of hematuria, dysuria, incontinence, frequency, urgency, or retention Also used in the diagnosis of conditions that cause blockage of the urethra Tissue biopsy can be performed.
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Nursing Diagnosis Impaired urinary elimination Urge urinary incontinence Ineffective coping Pain
Stress urinary incontinence Reflex urinary incontinence Toileting self-care deficit Disturbed body image
Functional urinary incontinence Risk for impaired skin integrity Risk for infection
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Urinary retention
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Planning NANDA-I Nursing Diagnosis with nursing diagnosis statement Impaired urinary elimination related to microorganisms in the urinary tract as evidenced by urgency, frequency and reports of burning with urination.
Nursing Outcomes Classification (NOC) Urinary Elimination (0503) Absence of urinary frequency (050331)
Nursing Interventions Classification (NIC) Urinary Elimination Management (0590) Instruct patient to monitor for signs and symptoms of urinary tract infection.
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Planning (Cont.) COLLABORATION AND DELEGATION • UAP often aid patients in toileting. The nurse must communicate assessment parameters, such as measuring the amount of urine, noting its color, and determining the frequency. The nurse must stress to the UAP the necessity of documenting voiding patterns. • Nurse continence specialists may need to be consulted to teach pelvic floor exercises. • Physical therapists can design a plan to increase overall muscle strength. • The family may need to alter the home environment to accommodate the patient’s elimination needs, depending on physical limitations.
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Implementation and Evaluation (Cont.)
The focus of each goal is directly related to the identified nursing diagnosis, which in turn determines what interventions are most appropriate for each patient. The nurse must focus on activities that will help the patient with compromised urinary elimination return to the normal state of function or to adapt to changes in the state of function. Ongoing assessment and follow-up are needed to assure quality in the care provided and to determine need for further nursing interventions. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Patient Education and Health Literacy
Instruct patients and families on safe transfer techniques for individuals with limited mobility needing voiding assistance. Instruct patients to respond promptly to urge to avoid urinary retention and reduce infection risk. Emphasize the importance of maintaining fluid intake to help flush the urinary system. Instruct patients to promptly report pain or burning on urination; changes in urine color, odor, or clarity; or changes in voiding patterns. Teach patients the importance of taking medications as prescribed. Instruct patients and families in desired or adverse side effects that may influence the patient’s urinary elimination pattern. Stress the importance of maintaining fluid intake or restrictions based on the medication.
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Patient Education and Health Literacy (Cont.)
Reinforce with female patients proper aseptic technique, including washing front to back to maintain cleanliness. Remind male patients to retract foreskin, if present, to thoroughly wash the urinary meatus. Be sure to stress the importance of drying the area thoroughly to prevent skin breakdown or irritation. Teach proper care of indwelling catheters and the perineal area, including emptying and cleaning the device, maintaining a closed system, and bladder irrigation, or flushing, if necessary. Arrange for a wound ostomy continence nurse (WOCN) to teach patients with a urinary diversion appropriate care for the stoma, drainage devices, and skin.
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Home Care Considerations • • •
• • •
Assessing the home for safety issues related to urinary elimination is important. The patient must be able to easily access toilet facilities. Adequate lighting should be ensured. Necessary assistive and safety equipment, such as grab bars and raised toilet seats, should be in place in the home prior to discharge, as needed. Bedpans and a bedside commode, if warranted, should be in the home ahead of time. Supplies necessary for catheterization and catheter care, for urinary diversions, and for incontinence care should be purchased. Appropriate referrals to home health or social services should be made prior to discharge. Services such as home health aides for assistance with ADLs should be confirmed. Community resources such as the United Ostomy Association and National Association for Continence should be identified as a resource for patients and their families. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Safe Practice Alert!
The home environment should be assessed for factors that may interfere with toileting. Distance to the toilet, physical layout of the toileting facilities, clutter, stairways, rugs, and inadequate lighting may put ambulatory patients at safety risk.
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Promoting Normal Urinary Patterns in a Health Care Facility
In the health care facility, there are often conflicts with a person’s normal routine. Proper integration of the patient’s habits into daily care will aid in preventing elimination issues. Safe Practice Alert!
Medications such as diuretics may cause frequency or urgency, potentially compromising patient safety risk. Instruct patients who are on falls precautions to ask for assistance prior to ambulation for toileting. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Bedpan and Urinal
The urinal is used by a patient while standing, sitting, or lying down. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Assisting a patient with a urinal
Background • Routine urination and complete emptying of the bladder prevents many complications. • Encourage routine use of the urinal for male patients who are unable to ambulate to the bathroom.
Documentation concerns • Document the quantity, color, quality, and odor of the urine. • Note the stream characteristics. • Monitor frequency of urination.
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Safe Practice Alerts!
Urine color, clarity, and odor should be assessed prior to disposal. Urine quantity must be measured before it is discarded to ensure accurate I&O records. Dehydration can pose a risk for patients trying to control incontinence problems by avoiding adequate fluid consumption. Dehydration may affect the patient’s mental status, further contributing to risk. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Bedside Commode
A bedside commode is a chair with a toilet seat top that has a container underneath to collect urine or stool for the patient who is unable to get to the bathroom. The container is removed for emptying and cleaning. Use of a bedside commode is more conducive to elimination than the bedpan. A patient may need to use a bedside commode if weak or unsteady, if the patient is at risk for falling, or becomes short of breath when ambulating. It should not be used for the patient who is unable to stand, who is maintained on strict bed rest, or who is at safety risk in an upright position. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Promoting Normal Urinary Patterns in a Health Care Facility (Cont.)
Privacy
Toileting schedule
If possible, the patient should be given time and privacy to void. Determining the patient’s toileting pattern may assist the person with urinary elimination. The patient should be encouraged to void at regular intervals whether urge is felt or not.
Fluid intake
Increasing fluid intake will increase urine production in the patient without renal or cardiac dysfunction. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Findings:
Patient is able to palpate bladder, indicating bladder distention. During palpation, patient states she has the sensation of bladder fullness. Patient complains of dribbling frequently and being unable to urinate.
What are the specific assessment activities that produced these findings? What other assessment questions should be asked?
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Monitoring Intake & Output (I&O)
Intake includes all food and oral fluids as well as tube feedings and intravenous fluids.
Oral fluids are recorded in milliliters (mL) according to the size of the container from which they are consumed. Ice chips are documented as approximately one half of their volume. The volume of tube feedings and intravenous therapies (both maintenance and piggy back) are noted on the can or bag in which they are supplied.
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Monitoring Intake & Output (I&O) (Cont.)
Output is measured by collecting it in bed pans, urinals, urinary catheters, drains, ostomy bags, nasogastric tubes, or collection devices commonly referred to as urine “hats” placed in the front of a toilet or bedside commode.
From Birchenall JM, Streight E: Mosby ’ s textbook for home care aide, ed. 3, St. Louis, 2013, Mosby.
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Intake and Output Calculation POSITIVE BALANCE Intake Output Oral fluid = 700 mL Urine = 940 mL IV fluid =1250 mL Vomitus = 50 mL 8-hour Intake Total = 8-hour Output Total = 1950 mL 990 mL I&O Balance = +960 (= 1950 - 990)
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Intake and Output Calculation (Cont.) NEGATIVE BALANCE Intake Output Oral fluid = 100 mL Urine = 640 mL Tube feeding = 480 mL Hemovac drainage = 400 mL 8-hour Intake Total = 580 8-hour output total = mL 1040 mL I&O Balance = −460 (= 580 - 1040)
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Quick Quiz! 3. A young girl is having problems urinating postoperatively. You that children may have trouble voiding: A. In bathrooms other than their own. B. In a urinal. C. While lying in bed. D. In the presence of a person other than their parents.
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Kegel Exercises
Kegel exercises help keep the female pelvic floor toned, which reduces the risk of incontinence. If performed correctly and regularly, Kegel exercises have been shown to strengthen the pelvic floor muscles which the uterus, bladder, and bowel.
Improvement is normally seen in approximately 8 to 10 weeks.
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Nursing Care Guideline
Kegel exercise techniques
Background • Kegel exercises are also known as pelvic floor exercises. • They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence. • Exercises can be done while sitting or standing. Documentation concerns • Document that patient education was provided.
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Prevention of UTIs
Prevention is key! Instruct patients about ways to prevent infection or recurrence:
Avoid wearing tight-fitting clothing. Drink at least eight 8-ounce glasses of water each day Urinate when the urge is felt. Women and girls should wipe “front to back.” Urinate after sexual intercourse. Showers are preferred instead of baths. Good perineal hygiene is essential. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Prevention of UTIs (Cont.)
Treatment for a UTI requires antibiotics
Symptom relief may be quick: 1-2 days Kidney infections may take weeks to resolve Severely ill people may need hospitalization with IV antibiotics
~80% of UTIs are the result of catheterization
Avoiding the use of indwelling catheters is a primary method for UTI prevention.
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Case Study (Cont.)
Nursing diagnosis: Urinary retention related to weakened detrusor muscle and recent removal of indwelling urinary catheter Goal: Mrs. Vallero will have normal micturition within 1 month. What expected outcomes would you establish to measure goal achievement?
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Urinary Catheterization
Urinary catheterization is most often performed through introduction of a catheter into the patient’s urethra. Straight, Foley, triple-lumen, and Coudé catheters are used for urinary catheterization.
Modifi ed from Wein AJ: Campbell-Walsh urology, ed. 9, Philadelphia, 2007, Saunders.
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Urinary Catheterization (Cont.)
Most indwelling catheters (commonly referred to as Foley catheters) have two lumens: one for filling a balloon at the tip of the catheter to “anchor” it in place and the other for draining urine. Coudé catheters are a special type of double-lumen, indwelling catheter that are slightly stiff and bent at the end allowing the catheter to more easily through a partially constricted urethra. Triple-lumen catheters are used for bladder irrigation. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Skill 41-1: Urinary Catheterization: Insertion and Care PURPOSE: Urinary Catheters Are Used To: Assess bladder function Accurately monitor urinary output Obtain urine specimens Manage urinary incontinence Irrigate the bladder Relieve bladder distention and discomfort Manage urinary Instill medications into the retention bladder Allow for healing after surgical procedures
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Skill 41-1: Urinary Catheterization: Insertion and Care
Collaboration and delegation
Inserting a straight catheter may be delegated to UAP) without a nurse’s assistance: • Following assessment of the patient • Depending upon the state and institution’s policies and procedures • Provided the UAP has received the appropriate specialized training
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Skill 41-1: Urinary Catheterization: Insertion and Care
Collaboration and delegation
UAP should report any of the following to the nurse: • Patient reports of pain before, during, or after the procedure; • Sores, wounds, irritations, or lesions noted; and/or • Difficulties encountered while performing the procedure.
UAPs should be instructed in: • Sterile technique, • Appropriate procedure and timing, and • Required documentation.
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Skill 41-1: Urinary Catheterization: Insertion and Care
Evidence-based practice
To prevent catheter-associated urinary tract infections, “insert catheters only for appropriate indications, and leave in place only as long as needed. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.” Anchoring of the catheter is imperative, not only to prevent inadvertent dislodgement, but also to prevent pressure ulcers. Intermittent catheterizations have been shown to have a lower incidence of UTIs then do indwelling catheters in acute-care facilities, even when ing for the same time frame of catheter necessity.
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Case Study (Cont.)
Interventions for urinary retention care include:
Assist with toileting every 2 to 3 hours while awake. Instruct the patient/family to record urinary output as appropriate. Have Mrs. Vallero take a warm bath if unable to urinate.
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Skill 41-2: Closed Bladder Irrigation
Purpose: Bladder irrigation is performed to:
Maintain patency of catheters, As a postoperative procedure for genitourinary surgeries, and Decrease genitourinary complications (such as infections).
Evidence-based practice
“Unless obstruction is anticipated (e.g., as might occur with bleeding after prostate or bladder surgery), bladder irrigation is not recommended. Routine irrigation of the bladder with antimicrobials is not recommended.” Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Skill 41-2: Closed Bladder Irrigation
Collaboration and Delegation
Bladder irrigation may not be delegated to UAP without a nurse’s assistance. UAP helping to care for the patient should report any of the following to the nurse: • Patient complaints of pain before or after the procedure; • Clots noted in output; • Change in color, odor, consistency, or amount (COCA) of output; • Sores, wounds, irritations, or lesions noted; • Fever or other changes in vital signs.
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Case Study (Cont.)
Sandy talks with Mrs. Vallero the next evening. The patient’s care plan incorporates scheduled voiding and oral fluids. She palpates Mrs.Vallero’s bladder and then assists her to the toilet. After making sure she is comfortable and leaving the call light in place, Sandy leaves Mrs. Vallero to void on her own. She returns to measure Mrs. Vallero’s urinary output and evaluates for bladder residual using an ultrasound bladder scan. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Discontinuing an Indwelling Catheter
Indwelling urinary catheters should only be placed when indicated and should be removed as soon as possible. Catheter use is appropriate:
For relief of acute urinary obstruction or retention During some surgical procedures To accurately measure urine in critically ill patients During perineal or sacral wound healing in incontinent patients When a patient is immobilized for an extended period of time For patient comfort at end of life Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Discontinuing an indwelling catheter
Background • Indwelling catheters are a primary source of urinary tract infections (UTIs) and should be removed as soon as possible. • The Centers for Disease Control and Prevention (CDC) has issued guidelines for insertion, use, and removal to aid in decreasing catheter-associated UTIs. • The patient may experience burning and difficulty voiding, as well as frequency or retention, after removal.
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Nursing Care Guideline (Cont.)
Discontinuing an Indwelling Catheter (Cont.)
Documentation concerns • Record urinary output. • Document any difficulties with performing the procedure, as well as the patient’s response to the procedure. • Note any patient education that was done. • Record the findings of the urinary assessment after catheter removal, including
The quantity of urine, and frequency of urination, and The color, odor, consistency, and character of the urine.
• Include any difficulty encountered by the patient with urinary retention and/or bladder distention.
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Nursing Care Guideline (Cont.)
Discontinuing an Indwelling Catheter (Cont.)
Evidence-based practice • Postoperative patients should have an indwelling catheter removed within 24 hours of surgery unless there are other appropriate reasons for the catheter to remain in place. • Some studies have been done regarding whether or not to clamp the catheter prior to removing it. The evidence leans slightly in the direction that it is better to leave the catheter unclamped so the urine is flowing freely as the catheter is removed. Additional studies have shown that there have been fewer cases of bacteriuria when this practice is applied.
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Routine Catheter Care
Catheters should be inserted using aseptic technique and sterile equipment, as recommended by the CDC. Once the catheter is placed, the urethral meatus should be cleansed with soap and water once or twice daily. Preconnected closed drainage urinary catheterization systems should be used to reduce risk of interruption of the system by staff or patient’s family. Catheters should be changed if debris or encrustation of the catheter is noted. Catheter bags should be emptied when two thirds full.
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Evidence-Based Practie
Urinary catheter infection prevention
It is imperative that catheter bags be kept below the level of the bladder at all times to prevent reflux of urine into the bladder, which may lead to catheteracquired urinary tract infection (CAUTI).
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Suprapubic Catheters
Suprapubic catheters are inserted directly into the bladder just above the pubic bone. Surgical placement of a suprapubic catheter may be undertaken if urethral catheterization is either contraindicated or unsuccessful. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Condom Catheters
Condom catheter use is less likely to lead to bacteriuria, UTI, and death, than use of indwelling catheters in patients who retain urine. However, condom catheters are not without risk: Skin necrosis, penile strangulation and urethrocutaneous fistulas, dermatitis, skin erosion, pain, and localized infection have been reported. Male patients report that condom catheters are more comfortable and less painful than indwelling catheters. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline
Applying a condom catheter
Background • A condom catheter (also known as an external catheter or a Texas catheter) is used as an incontinence solution for the male patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline (Cont.)
Applying a condom catheter (Cont.)
Documentation concerns • Record any difficulties encountered with placing the catheter. • Document urine output and the quantity, color, and odor of the urine. • Document neurovascular monitoring of the penis.
Evidence-based practice • “The use of condom catheters is less likely to lead to bacteriuria, symptomatic UTI, or death than the use of indwelling catheters” (Saint et al, 2006) • It is important to note that, without proper care and routine assessment, condom catheters can cause skin breakdown and other complications that can lead to external infections Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Perineal Care
Skin care is important in patients with urinary elimination issues, including those with indwelling catheters to help prevent infection. Frequent perineal care is necessary, although use of harsh soaps, bubble baths, powder, or sprays, which can irritate the urethra, leading to inflammation and infection, should be avoided. The perineal area should be cleansed with soap and water or no-rinse cleansers frequently and dried thoroughly. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Urinary Diversion Care
Patients should be encouraged to provide their own urinary diversion care, as much as possible. Individuals who have recently undergone diversion surgery will require a demonstration and patient education on how best to manage and care for their particular type of urinary diversion. Participation in a group of others with urinary diversions may be helpful in addressing individual concerns. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nursing Care Guideline (Cont.)
Urinary diversion care
Background: • Various disease processes or disorders, such as cancers, spinal cord injury, or renal calculi, may necessitate the ureters to be diverted externally from the meatus of the bladder to the abdominal wall.
Documentation concerns • Document patient urinary I&O. • Note stoma condition and skin appearance. • Record color, odor, consistency, and amount of urine.
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Nursing Care Guideline (Cont.) TYPES OF URINARY DIVERSIONS The ureters are connected to the The small bowel resection is resected small bowel. brought to the abdominal wall. An ileal neobladder is the most A stoma is created in the common continent urinary abdominal wall. diversion The patient catheterizes the Urine drains through the stoma stoma to drain the urine, if into a collection bag/device. necessary. A section of intestine is used to A stoma is created in the create a pouch to hold urine. abdominal wall. An ileal conduit is the most common noncontinent urinary diversion. A section of small bowel is resected.
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Obtaining Urine Specimens
The nurse is responsible for collecting urine specimens.
Specimens may be collected for routine urinalysis via normal voiding into a specimen cup or into a clean urinal or bedpan. For culture and sensitivity testing, urine is collected by the clean catch, or midstream, method, using a sterile specimen cup. Specimens can also be obtained by performing a straight catheterization using sterile technique or by removal of a specimen from the tubing of an indwelling catheter or urinary diversion collection bag. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Case Study (Cont.)
Ask Mrs. Vallero about her urge to void, sensation of bladder fullness, and dribbling episodes. Have Mrs. Vallero keep a log of her pattern of elimination, including urine output volumes with each voiding, during the 1-month period. Ask Mrs. Vallero if she continues to have lower abdominal pain.
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Evaluation
Sharing evaluation findings with patients helps them recognize goal achievement and move closer to healthy urinary elimination patterns regardless of previous challenges. Prevention of kidney disease, urinary tract infections, and secondary complications such as skin breakdown related to incontinence is ongoing, whether the patient is in a health care facility or at home.
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Case Study (Cont.)
Mrs. Vallero is concerned about regaining her urinary function. Sandy develops the following outcome for her: At the end of the teaching session, Mrs. Vallero will be able to describe approaches to promote normal urinary elimination habits. What teaching strategies would you put into the plan? What evaluation strategies would you use?
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