Urinary elimination; Georgia College State University; Susan Darby, RNC, MSN

Student responsibility (p. 1256-1258)

·         Physiology of urinary elimination: kidneys, ureters, bladder, urethra, and urination. 

Urination

      Micturition, voiding, and urination all refer to the process of emptying the bladder.

Developmental factors affecting voiding

·         Infants: Brick dust: It is not unusual for the newborn’s first voiding to be pink tinged due to an accumulation of uric acid crystals.

·         Preschoolers: Myelinization of the sacral spinal segments that control the bladder is complete at 12-18 months. Children can then perceive bladder fullness. When a toddler begins _______, it is a good indicator of the maturation of the spinal cord. At approximately 2 ˝ to 3 years of age, can perceive bladder fullness, hold urine after the urge to void, and communicate the need to urinate. Which sex takes longer to potty train? ______ At 3 years of age, children usually achieve daytime continence (the ability to control urination). Nighttime continence may not occur until 4 or 5 years of age.

·         School-age children: Enuresis: Involuntary passing of urine when control should be established (about 5 years of age). Nocturnal enuresis: Involuntary urination at night. 

·         Elders: As a result of cardiovascular changes that occur with aging, most older adults experience decreased perfusion to the kidneys. The kidneys become a less effective regulator of the body’s extra cellular fluids. The older adult is at risk for: Urinary incontinence:  Involuntary loss of urine from bladder. Nocturia frequency: The need for the older adult to arise during the night to urinate. Urinary urgency: Unable to voluntarily to delay the urge to void. Due to the capacity of the bladder and its ability to empty diminishes with age. Urinary retention: Inability to empty bladder of urine (due to loss of muscle tone). Predisposes them to urinary tract infections (UTI).

Psychosocial factors (name 3)

1.

2.

3.

Body position

1.

2.

·         Fluid and food intake: Foods with a high water content (soup, Jell-O, fruits, vegetables) _____urine output. Large quantities of salty foods without increasing water intake _____urine output. Alcohol and foods that contain caffeine (diuretic) _____urine output.

·         Medications: Student responsibility: After reading (Box 47-1; p. 1260), which of the following drugs cause urinary retention (name four)?  Aspirin, antihistamine preparation, furosemide, anticholesterol, antispasmodic, antipsycotic, antibiotic, and antihypertensive.

·         Diuretics (___ urine output).

·         Nephrotoxic antibiotics: Early signs of nephrotoxicity are manifested by changes in the color of urine (urine is cloudy, smoky, or pink).

·         Muscle tone: If the client is obese, weight loss methods should be discussed to help in the control of urinary ________.

·         Pathological conditions: Extensive burns, vomiting, diarrhea, excessive diaphoresis and wound drainage, or blood loss from trauma or surgery. ______ urine output.

·         Obstruction of urine flow: Structural abnormalities within the urinary tract, urinary tumors (press against urinary tract), prostatic enlargement, and catheters that become plugged or kinked. Hydronephrosis: Distention of the kidney pelvis with urine secondary to the increased resistance caused by obstruction to urine flow.  If unrelieved, can cause permanent kidney damage.

·         Other factors: Infections of the urinary tract. Hypotension (_____urine output).

·         Surgery and diagnostic procedures: A patient should be able to void 10 hours after surgery. Spinal or regional block anesthesia impairs the sensory and motor impulse that control voiding causing urinary retention and edema.

·         Anesthetic agents: Slow the glomerular filtration rate (GFR) and reduces urinary output. GFR: The number of ml of filtrate made by the kidneys per minute. The stress of surgery triggers the release of antidiuretic hormone (ADH), which decreases urinary output. Surgery involving the urinary tract, intestines, or reproductive systems may need a retention catheter.

Altered urine production:

·         Polyuria or Diuresis: poly = many. Urine output of greater than 2,500 to 3,000 ml in absence of concurrent increase fluid intake.

·         Polydipsia: Excessive thirst.

·         Oliguria: Oligo = small. Urine output of less than 500 ml in 24 hours.

·         Anuria: An = Without; away from; not. The formation and excretion of less than 100 ml of urine in 24 hours.

·         Dialysis: A technique by which fluids and molecules pass through a semipermeable membrane according the rules of osmosis.

Altered urinary elimination:

·         Urinary frequency: Voiding at frequent intervals.

·         Nocturia:  Noct: night; Uria = urine. Voiding two or more times per night. Indication of congestive heart failure (CHF).

·         What does dysuria mean?

·         Urinary hesitancy: A delay and difficulty in initiating voiding; often associated with dysuria.

·         Hematuria: Hema = blood.

·         Pyuria: pus in urine. 

Case Study

1.       In the nursery, you are caring for Baby Girl Jones who is healthy and newly born.  What color would you anticipate this infant’s first voiding to be?

 

2.       The next day, you are taking care of the baby’s mother, Gabriel.  After removing Gabriel’s Foley catheter, she does not have the urge to void. Since surgery triggers the release of the ADH, how will this affect her urine output?

 

3.       Gabriel is confined to bed after the birth due to postpartum complications. What two interventions would you implement for her to promote urinary elimination?

a.

b.

4.       You assess and report Gabriel’s urine output of less than 30 ml. What medical term would you use to document this in her chart?

 

5.       The obstetrician orders for Gabriel to have bathroom privileges. When Gabriel voids, she complains of a burning sensation on urination. How would you document this in the chart?

 

6.       Gabriel confides to you that her 7 year old boy is bed wetting at night. What is this condition called?

 

7.       Gabriel reports that her son goes to the bathroom frequently. After measuring the urine for 24 hours, the total urine output is 2000 mL. What is this called?

 

8.        Your other patient, Mrs. Ingle, tells you, “The need to urinate comes on me all of a sudden, and it feels as though I have to go immediately –that I can’t wait.” How would you document this in the chart?

 

9.       Mrs. Ingle is 70 years old. What are some common complaints for the older adult related to urinary elimination?

a.

b.

c.

d.

Urinary incontinence

·         Stress incontinence: A small loss of urine as a result of coughing, sneezing, laughing, and jumping. These activities increase abdominal pressure. Associated with the weakening of the pelvic floor muscles. Instruct client to avoid bladder irritants (name four):

1.

2.

3.

4. 

·         Urge incontinence: An involuntary loss of urine after a strong feeling of the need to urinate. Associated with UTI, diuretics, consuming caffeine and alcohol, increased fluid intake, and after removal of catheter.

·         Reflex incontinence: Seen in patients with neurological problems - spinal cord lesion, Cerebral Vascular Accident (CVA), or brain tumor. The person is unable to sense bladder fullness, and the bladder empties when a certain degree of bladder stretch occurs.

·         Functional incontinence: Inability or unwillingness of a person with normal bladder and sphincter control to reach the bathroom in time to void. Examples: Environmental barriers: A poorly lit, cluttered room. Physical barriers: Raised side rails or call bell. Sensory and cognitive factors: Confusion, disorientation, and sedatives. Motor deficits: Impaired gait and loss of fine motor control needed to release necessary clothing.

·         Total incontinence: The continuous, involuntary, unpredictable loss of urine from a distended bladder. Used when the incontinence does not fit any other category and does not respond to usual treatment methods.

Critical thinking   

1.       Jack suffered a spinal cord injury in a motorcycle accident nine months ago. He has no awareness of bladder filling, urge to void, or feelings of bladder fullness. He reports loss of urine at fairly frequent intervals- about every two hours. What type of incontinence is he most likely experiencing?

 

2.       Jane has a history of three full-term pregnancy. What type of incontinence is she at risk for?

 

3.       Peter complains of involuntary urination with little or not warning. What type of incontinence is he most likely experiencing?

 

4.       You should always clear a client’s room of environmental barriers to prevent what type of incontinence?

 

Neurogenic bladder

·         Interference with the normal mechanisms of urine elimination in which the client does not perceive bladder fullness and is unable to control. the urinary sphincters. Result of impaired neurologic function.

Assessing: Nursing history

True or False

1. Clients find it easier to describe their normal elimination pattern than to describe alterations in urinary elimination. ___

2. The nurse should not use words like “potty” or “peeing” because this is unprofessional. ___

3. Clients who have experienced problems with urinary retention, incontinence, and flow over long periods of time may not report these conditions unless specifically asked. ___

      “When did you last urinate?”

      “How many times per day do you urinate?”

      “Do you urinate a small, medium, or large amount of urine?”

      “Do you wake during the night to urinate?”

      “Have you noticed any problems with passing your water?” 

Physical assessment: Critical thinking

      Mrs. Pagana’s history indicates that she has a problem with urination, so you assess her skin for color texture, tissue turgor, and edema. What is the rationale for these added assessments?

 

      Inspect for a bulge above the symphysis pubis. Percussion Draw an arrow of where you would begin and end to percuss the bladder.

      Percussion is the most reliable method for determining the degree of bladder distention. Distended bladder:        Empty bladder:           Palpation: Bladder distention of more than 600 ml can often be palpated.

Critical thinking: Assessing urine

      Urine in the bladder stimulates stretch receptors and triggers the need to void. In the adult, the need to void is signaled after how much urine enters the bladder? _______ Color: Ranges from light to a darker yellow, to a dark yellow-brown (amber). Clarity: Clear without sediment. Odor: Aromatic.

Case study

1.       You are assessing an adult patient, Miss Pope, for renal function. You note that in the past 24 hours, she has voided 850 cc of urine. What does this finding indicate?

 

2.       When assessing the color of Miss Pope’s urine, you note the color to be dark amber. What does this assessment indicate?

 

3.       You would notify Miss Pope’s physician if her urinary output falls below ___ml per hour.

4.       Mrs. Wilson presents to the doctor’s office for a routine checkup. A urine specimen is obtained and is noted to be 250 mL of light yellow, cloudy, odorless urine. Which characteristic of the urine specimen is abnormal?

 

Measuring urinary output

      Urine output should be within approximately ____ to ____ of intake within a 24-hour period. Absence of voiding during any 8-to 12 hour period suggests acute urinary retention.

Measuring residual urine

      Urine remaining in the bladder following the voiding. Client voids frequent, small amounts (50 to 100 ml).Nursing interventions: Assess for a distended bladder. After obtaining a physician’s order, catherize the client immediately after voiding and measure both the void and catheter amount. Critical thinking: You catherize a bed-bound patient, Mrs. Moss, just after she voids 600 cc of urine. The catherization procedure yields an additional 275 cc of urine. What is an appropriate nursing diagnosis for Mrs. Moss?

 

Diagnostic tests:

·         Random specimen: Used when sterile specimen is not required. Can be collected in urinal, bedpan, hat, or from a specimen cup. Nursing care: Teach patient to avoid contaminating specimen with feces or toilet paper. If a woman is menstruating, note this finding on the specimen.

·         24 hour specimen: Collect urine for 24 hours. Discard the first morning urine. May void into urinal, hat, or bedpan then transfer to urine container. Keep urine container in the fridge or on a bucket of ice. Discarding even a small amount of urine invalidates the test results and must start all over again (place sign over bed and in bathroom.). If there are feces in the sample, the test has to be started all over again. At the end of the 24 hours, ask the patient to empty bladder and add this urine to the collection container.

·         Collecting urine from children: Plastic collection bag is most appropriate for infants and small children.

·         Specific gravity: What is used to measure the weight or concentration of urine as compared to water? __________ Normal range: NR: 1.010 to 1.025 g/ml. Low: Less concentrated urine or overhydration. High: More concentrated urine or fluid volume deficit. Critical thinking: Jimmy is admitted to the medical unit with a medical diagnosis of dehydration. What would you expect his urine-specific gravity to be?

·         Reagent strips (dipsticks): Determines the amount of substances (e.g. protein, glucose) in the urine. Protein: If found in the urine, is a sign of __________ injury.

·         Blood Urea Nitrogen (BUN) level: A measure of blood level of urea, the end product of protein metabolism.

·         Creatinine clearance (requires two test)

1.

2.

o        Uses 24-hour urine and serum creatinine levels to determine the ___.  A high serum creatinine level is a reliable indicator of impaired _____ function. NR: Men: 95-104 ml/min; Women: 95-125 ml/min.

·         KUB: X-ray of the abdomen to observe kidneys, ureters, and bladder.

·         Intravenous pyelogram (IVP): X-ray that visualizes the urinary system by the use of a radiopaque dye. Assess for allergies (name two):

1.

2.

o        As the dye is injected, the client may experience (name two):

1.

2.

 

·         Cytoscopy:  Cytoscope: Flexible tube with light at the end. Inserted into the urethra and guided into the bladder to look for tumors, stones, or structural problems. Specialized instruments can be passed through the cytoscope to remove small stones or to take tissue biopsies. Patient teaching (name 4):

1.

2.

3.

4.

o        After the procedure: Assess for hematuria (indicates hemorrhage), urinary retention, bladder spasms, and symptoms of UTI

·         Urodynamic studies: A special catheter measures the pressure in the bladder, urethra, and abdomen. Electrodes measure sphincter muscle activity. Computer records and integrates information.

Student responsibility

      After reading diagnosing, planning, and implementing (p. 1265- 1269), name medical problems that would require a client to increase or decrease their fluid requirements. Read Home care assessment on p. 1267. 

Case study

·         Jessica, a 24 year old female, comes to the ambulatory clinic with complaints of cloudy urine with offensive odor, dysuria, severe burning on urination, frequency and urgency. What do you think is wrong with her?

 

·         Critical thinking: The Nurse Practitioner (NP) orders a clean catch urine. Which is the preferred method for obtaining this specimen? Voiding or Catherization. Rationale: To decrease the risk of introducing microorganisms into the urinary tract.

·         You need to instruct Jessica on the correct technique for obtaining a clean catch urine. How would you teach her to do it?

 

 

·         How would you teach a male patient to cleanse for a clean catch urine?

 

 

·         True or False: A clean catch sample is acceptable if contaminated with stool, vaginal secretions, or menstrual blood.

·         Send clean catch specimen to laboratory within 15 minutes, or place specimen in refrigerator. Rationale: Microorganisms grow quickly in urine, especially at room temperature.

·         If specimen is for microbiology testing, it must be sent immediately and not refrigerated. Rationale: Refrigeration retards bacterial growth.

·         The NP diagnoses Jessica with cystitis and prescribes Bactrim Double Strength (DS) one orally BID x 3 days. The NP instructs Jessica to take all the pills then return to the clinic for a urine culture. Patient teaching: Bactrim DS

 

·         Jessica asks, “How did I get this urinary tract infection.” You would explain that cystitis is caused by an ascending infection from the __________.

·         Jessica asks you, “What can I do to relieve this pain?” What would you include in her teaching plan? Heat or cold therapy?  Rationale: To promote relaxation and help relieve urgency, discomfort, and spasms.

·         Avoid bladder irritants  

·         Void at least every ____ hours and empty the bladder at each voiding. Rationale: To avoid stagnant urine from remaining in bladder.

·         You teach Jessica the importance of increasing her fluid intake to flush microorganisms out of the urinary system. Jessica responds, “Exactly how much fluids should I drink per day?”

·         True or False: Cranberry and blueberry juice prevents bacteria from adhering to bladder wall and may prevent another UTI. ___

·         Jessica is prescribed phenazopyridine hydrochloride (Pyridium) 200 mg orally TID x 2 days. Drug action: Provides an analgesic effect on the bladder mucosa. Pyridium turns the color of the urine ____________. Common side effects: Headaches, GI disturbances, and rash. 

·         Avoid tight fighting clothing and noncotton underwear. Avoid harsh soaps, powders, bubble baths, and vaginal sprays. Jessica asks, “Is douching recommended?” Rationale:

 

·         Void 15 minutes after intercourse to flush any sperm out of urethra. Wipe front to back. Rationale:

 

·         Adequate perineal care is essential during menstruation and during the postpartum period.

Managing urinary incontinence:

·         Bladder training: Client postpones voiding, resists or inhibits the sensation of urgency, and voids according to a timetable rather than according to the urge to void.

·         Habit training: Attempts to keep clients dry by having them void at regular intervals. Also referred to as timed voiding or scheduled toileting.

·         Prompted voiding: Supplements habit training by encouraging the client to try to use the toilet (prompting) and reminding the client when to void.

·         Critical thinking: Joe has a spinal-cord injury and is starting on a bladder training program. What program requires Joe to void on a regular schedule?

 

·         Case Study: Ethel Jackson is a 78 year old client with urinary incontinence. Ethel lives independently at home. She reports that she has curtailed many of her social activities due to her incontinence. How would you instruct Ethel on managing her incontinence (name four)?

1.

2.

3.

4.

·         Pelvic muscle exercises: You are instructing Ethel Jackson, how to perform Kegel Exercises. You teach Ms. Jackson that Kegel exercises facilitate urinary control and prevent incontinence by tightening what muscles?

o        Kegel Exercises: Tighten the perineal muscles together and hold the squeeze for 3 seconds. Relax the muscles. Repeat 10 times TID. Exercises can be performed sitting up, lying down, or standing. Another method: Sit on the toilet and start and stop the flow of urine. Muscle tone can be restored in about 6 weeks of regular practice.

Student responsibility

      After reading maintaining skin integrity (p. 1271), answer the review question 47-2 on p. 1289.

External catheter

      Purpose: Provides a means of collecting urine and controlling incontinence without the risk of infection that an indwelling urinary catheter imposes.

      Provide privacy. Wash hands. Assist client to supine position with only genitalia exposed. With disposable gloves wash genitals with soap and water. Towel dry. Trim or shave excess pubic hair from base of penis, prn. Apply thin film of skin protector on penis shaft (found in kit). Allow to dry for 30 seconds. Apply the adhesive strip to the penis in a spiral fashion before placing the condom catheter. Rationale Prevent a constricting tourniquet effect on the penis that could impede circulation.

      A one inch space should be left between the penis and the end of the condom. Attach funnel end of condom to collection system. Tubing is taped leg or attached to a leg bag. Avoid kinks or loops in the tubing. Wash hands. Observe penis, 15 to 30 minutes after application for swelling or changes in skin color. Document procedure. Safety alert: Remove the external catheter daily to cleanse the penis and surrounding tissues and to assess the skin for any edema or areas of excoriation. Critical thinking: The wife of an elderly client, Mr. Jacobs, asks why her husband is wearing a condom catheter instead of having a “tube” inside of him. How would you respond?

 

Managing urinary retention: Flaccid bladder

      Weak, soft and lax bladder muscles. Critical thinking: Janet has multiple sclerosis and is diagnosed with a flaccid bladder. What technique could you teach Janet in order to assist with bladder training?

 

Urinary catheterization

·         Definition: Placing a flexible tube through the urethra into the bladder. Purposes: To drain the bladder for therapeutic purposes (surgery or inability to void). Critical thinking: Mrs. Alford is incontinent and requires frequent linen changes by the nursing staff. The nursing assistant suggests a urinary catheter be inserted. How would you respond?

 

·         Female anatomy: Labia majora, labia minora, clitorus, urethral opening, vagina, and anus. Male anatomy: Bladder, urethra, and meatus

·         Equipment: Light source. Inside wrapper is sterile field. Sterile gloves on top –carry extra pair of well-fitting gloves with you. Two drapes. Sterile cotton balls or swabs. Forceps or pick-ups for cotton balls. Cleansing solution. Water-soluble lubricant. Specimen container.

·         Foley catheter: Balloon at end that is inflated inside bladder. Pre-filled syringe with sterile solution to fill balloon. Balloon usually hold about 5-6 cc, but may hold 30 cc. Drainage bag.

·         Straight catheter: Inserted and removed as soon as bladder is empty. Plastic tray to collect urine (graduated). Select smallest usable size. 8 French for children and infants. 16 French for adults.

·         Special considerations: Sterile procedure! Tie hair back. Review procedure before you do it for the first time.

Procedure

·         Verify the physician’s orders and identify the patient.  Explain the procedure and rationale to client. Wash hands

·         Position the client: Female: Dorsal recumbent or Sims (on back with both legs drawn up). Male: Supine.

·         Set up light source. Open kit in convenient place. Save plastic bag cover for soiled items. Open sterile drape by corners maintaining sterility. Slide drape under buttocks (soft side toward patient). Don the gloves away from the sterile field. Second drape is optional. Cover gloves with corner of drape as you place over penis or perineum.

·          Open cleansing packet Pour solution over cotton balls or swabs. Open lubricant and place packet on end of catheter and leave in place. Put syringe on Foley balloon port. Check balloon and leave syringe attach.

·         Cleanse patient: Use each swab or cotton ball only once. Use forceps with cotton balls to keep dominant hand sterile. Use non-dominant hand to expose meatus. Male: Raise penis to 45 degree angle. Begin at meatus; retract foreskin if present. Cleanse in circular motion starting at meatus. Female: Fingers inside both labia majora and minora. One side first, than other. Last stroke of swab or cotton ball down center.

·         Insert catheter: Move tray closer (be careful), and grasp catheter. Insert 2-3 inches for female; 6-9 inches for male. Don’t force; have patient take deep breaths. Watch for urine. Insert about 1 inch further. Hold straight cath in place till bladder empty.

·         Indwelling Foley: Inflate balloon. Tape, leaving slack in catheter Male: Tape to lower abdomen or thigh. Women: Tape to thigh. Rationale: Taping the catheter reduces urethral irritation, allows drainage, and prevents excessive traction against the bladder wall.

·         Keep collection bag lower than bladder to prevent backflow of urine. Clean up area and reposition patient.

·         Document: Type of catheter, specimen, amount/character of urine, and patient’s response. Example 16 FR Foley catheter inserted with return of 500 cc of clear yellow urine. U/A obtained and sent to lab. Pt tolerated procedure well.

Case study

1.       You are inserting a straight catheter on Mrs. Chen and accidentally contaminate the catheter. Should you throw away the entire catheter kit or only replace the catheter you contaminate?

 

2.       During the straight catherization of Mrs. Chen, the catheter slips into the vagina. What will you do?

 

3.       While inserting a Foley catheter on Mr. Smith, he complains of pain after you inflate the balloon. What will you do?

 

4.       You need to send Mr. Smith to a chest x-ray today. He is ambulating but still has his indwelling catheter. What instructions should you give to the x-ray technician who accompanies Mrs. Smith to the radiology department to prevent backflow of urine?

 

5.       Mr. Smith is being discharged to home with a urinary-retention catheter. Part of the discharge instructions included encouraging the client to eat whole grains, cranberries, plums, prunes, and to limit fruit, vegetables, and milk products. What is the purpose of the instructions?

 

Ongoing assessment

·         Observe the flow, color, odor and abnormal constituents every 2 to 3 hours.

·         Intake and Output: Empty at least every shift.

Maintenance:

·         Wash meatus and catheter every shift with soap and water to prevent UTI. Drainage: Keep bag below bladder and keep off floor.

Collecting a sterile specimen

      Clamp tubing to allow urine to collect. Cleanse the aspiration port of the drainage tubing with alcohol. Insert needle into aspiration port. Draw urine sample into syringe by gentle aspiration. Transfer urine from syringe into a sterile specimen container.

Removal retention catheter

      Check order and if specimen is needed.

      Equipment Nonsterile gloves and 10 cc syringe. 

      Procedure: Identify the patient and explain procedure. May feel urge to void immediately after removal. Wash hands. Privacy.  Place pad or towel under catheter. Remove fluid from balloon never cut a balloon. Pinch catheter and have patient bear down as if to void. Remove smoothly and quickly. Empty bag and measure. Discard in red plastic biohazard bag. Teach the signs and symptoms of UTI. Measure output after removal. Should expect 250-400 cc and patient should void within 6-8 hours. Rationale When an indwelling catheter is in place for an extended period, the bladder may lose tone, contributing to urinary retention.

       Patient should maintain hydration.

Clean intermittent self-catherization

      Taught to clients with urinary retention to enhance their independence, reduce the risk of infection, and eliminate incontinence.

      Critical thinking: Janet has multiple sclerosis and is diagnosed with a flaccid bladder. You are planning to instruct her on clean-intermittent self-catherization. What would you assess prior to instructing Janet on the catherization procedure (name five)?

1.

2.

3.

4.

5.

Urinary irrigation

·         Purpose: Instillation of solutions to help remove mucus, blood clots, or other tissue in the bladder (particularly after GU surgery), and the application of medications to the bladder wall.

·         Closed method: Performed without disruption of the drainage system using a triple-lumen indwelling urethral catheter. Closed catheter irrigations may be either continuous or intermittent.

·         Triple lumen: First lumen inflates the balloon of the catheter to keep it securely inside the bladder. Second lumen removes urine into a closed drainage system. Third lumen connects to a container of sterile irrigating solutions.

·         Open method: Performed with a double-lumen indwelling catheter.  After cleansing the junction between the urethral catheter and the drainage tubing and using sterile technique, the catheter and drainage tube is disconnected. The solution is administered either with a sterile syringe or by gravity; then the catheter and drainage tube is reconnected. This method is associated with a higher risk of infection.

·         True or False: The irrigant is considered intake as it may be absorbed once it enters the bladder.

·         Case study: Mr. Adams had a transurethral resection of the prostate has an indwelling catheter. You notice that Mr. Adams has had less than 100 cc or urine over the last 4 hours. Upon talking with the surgeon, Mr. Adams is ordered bladder irrigations by the closed method.

1.       What type of irrigation is used?

2.       This physician’s order is not complete. What additional information would you need to obtain from the surgeon regarding the irrigation? 

 

Community based nursing

      A leg bag can be used during the day for a long-term indwelling catheter.

Case study

1.       Mrs. Shamrock is being sent home with an indwelling catheter. What type of solution would you instruct Mrs. Shamrock to cleanse the urinary drainage bag to prevent the growth of microorganisms? 

 

2.       Mrs. Shamrock tells you that she has been soaking in a warm tub to ease the irritating feeling from having a catheter. How will you respond?

 

Urinary diversion

·         Created when the bladder must be removed, for example, because of cancer or trauma. The ureters may be brought directly to the surface of the skin to form small stomas (cutaneous ureterostomy).

·         Ileal conduit: Ureters joined to bowel loop to drain urine into bag. Most common diversion and requires that the client wear a urine collection device continually over the stoma. Less chance of an ascending kidney infection.  

·         Critical thinking: What type of client would a urinary diversion procedure be performed?

 

Suprapubic catheter

      Catheter inserted through the abdominal wall above the symphysis pubis into the urinary bladder. Student responsibility: After reading page 1284, what type of nursing care would you provide a client with a suprapubic catheter?

After viewing the catherization video (20 minutes), answer the following questions:  

  1. True or False. Inspection of the lower abdomen is the most reliable method for determining the degree of bladder distention.
  2. What is the purpose of urinary catherization?

 

  1. When preparing to insert a catheter, what will you place on the tip?

 

  1. Designate if the following areas of the catheter must be kept sterile or clean. Mark “S” for sterile or “C” for clean.
    1. Tip ___
    2. Shaft ___
    3. Balloon port ___
    4. Drainage port ___
    5. Emptying the collection bag ___
  2. a. Where do you tape a catheter for a male?

b. For a female?

c. Why is it necessary to tape the catheter?

 

  1. When inserting a urethral catheter the nurse should:
    1. Instruct the client that the procedure will cause no pain or discomfort.
    2. Instruct the female client to hold her urethra perpendicular to her body to straighten the insertion pathway.
    3. Remember that intermittent catherization is a clean procedure, but insertion of an indwelling catheter is a sterile procedure.
    4. If continuous drainage is ordered, inflate balloon with prefilled syringe to check for defective balloon.
  1. Teaching regarding home care of modifications for the client discharged with an indwelling catheter should include:
    1. Explanation regarding the need to place the catheter bag on the side rail of the bed.
    2. Instructions on methods of kinking the catheter tubing to relieve intermittent bladder spasms.
    3. Information on signs and symptoms of urinary tract infection with directions of who to contact.
    4. The need to limit fluid intake in order to concentrate urine and promote urinary function.