CHAPTER 31 URINARY ELIMINATION AND CARE

INSERTING CATHETERS

- Safety: It is important to assess a patient for allergies to latex before inserting an indwelling urinary catheter. If the patient is allergic to latex, you will need to obtain a silicone catheter instead to prevent reactions. -Always check for allergies to povidone-iodine (Betadine) as well because it is provided in most catheter insertion kits for cleansing the meatus and surrounding area prior to insertion. -Safety: If the patient is allergic to Betadine, you will need to obtain a different cleaning agent according to your facility's policy. -The type of catheter and the reason for catheterization will determine which supply kit you use. -Safety: Contamination of the catheter or sterile field can lead to a catheter-associated UTI (CAUTI). -Insertion of a urinary catheter, in the hospital or another medical setting, requires stringent asepsis.

CONDOM CATHETER 2

- Texas catheter. -Used for males who are incontinent of urine to avoid the risk of infection related to insertion of an indwelling catheter. -It is similar to a regular condom and is applied by rolling it onto the penis. It is a condom-like sheath with a 2-inch drainage tube connector on the tip that connects to a urinary drainage bag. -The sheath collects the urine and allows it to drain through the drainage tube into the drainage bag, either a regular urinary drainage bag or a smaller bag that can be strapped to the thigh.

3-WAY CATHETERS

- Used in only one specific situation: -After a male patient has had a transurethral resection of the prostate, the surgeon will insert a triple-lumen catheter with a 30- to 60-mL balloon to provide traction and help control bleeding. -The third lumen in the catheter allows instillation of sterile fluid into the bladder during continuous bladder irrigation to help evacuate tissue and clots from the urinary bladder. -When the prostate gland enlarges in a male patient, it grows into the prostatic urethra and obstructs it, causing the opening through which urine can pass to narrow significantly. -In this situation, the enlargement of the prostate is not due to cancer but is a benign condition called benign prostatic hypertrophy. -A surgical procedure called transurethral resection of the prostate (TURP) is one option for treating this condition. In this procedure the physician removes the parts of the prostate that are blocking the urethra.

UROMETER

- is a small plastic measuring device attached to the urine drainage bag that accurately measures very small amounts of urine.

URINARY RETENTION

- is the inability to empty the bladder at all or the inability to completely empty the bladder. -With urinary retention, the kidneys are functioning normally and producing urine and the ureters are transporting the urine to the bladder to be stored, but for some reason the bladder is not emptying. -An obstruction such as a kidney stone, an enlarged prostate gland, a tumor, a pregnant uterus, an infection, or scar tissue may cause retention, UTIs, disorders or diseases of the nerves that regulate the bladder and urinary sphincters, postoperative complications due to anesthesia, inflammation, edema from surgery, and medications. -An enlarged prostate is a frequent cause of urinary retention in older men. The prostate gland surrounds the urethra, and when the gland enlarges, it constricts the urethra and can prevent the bladder from emptying.

SPECIFIC GRAVITY

-1.005-1.03=Less than 1.005 Overhydration; dilute urine due to kidney impairment -Greater than 1.03=Dehydration, hemorrhage, diabetes mellitus

pH

-4.5 TO 8.0 -A diet high in protein or cranberries will cause the pH to be lower, or more acidic; -a diet high in citrus fruits, dairy products, or vegetables will cause the pH to be higher, or more alkaline. -Determining the pH of the urine is helpful in the diagnosis and management of urinary tract infections (UTIs), which tend to make the urine more alkaline.

pH

-4.5-8.0=High pH (alkaline) Vaginal discharge, diet high in citrate -Low pH (acidotic)=Diet high in protein, cranberry juice

INTERMITTENT CATHETER IRRIGATION

-A catheter can be irrigated, or flushed, with sterile saline to rinse out sediment or mucus that may be blocking the openings on the tube in the bladder. -It is important to use good aseptic technique to prevent introducing pathogens into the closed urinary drainage system. -This is accomplished by using a sterile syringe and noncoring blunt needle or other needleless access device. - The sterile saline is drawn up as ordered from a sterile container into a 20-mL syringe. -The tube on the drainage bag contains an access port for this purpose. -Clamp the drainage bag tubing below the port. This causes the saline to go into the bladder and not simply drain into the bag.

CLEAN-CATCH URINE SPECIMEN

-A clean-catch, or clean-catch midstream, urine specimen (CCUA) is ordered to obtain uncontaminated urine for urinalysis (UA) -Instruct the patient to clean the urinary meatus with disposable antiseptic wipes prior to voiding. -Instruct the patient to begin voiding and then to stop the stream and continue voiding into the specimen container. -This removes contaminants from the skin and from the opening of the urethra that could enter the urine and become part of the specimen. It decreases the chance that the patient will be treated for a UTI due to a contaminated specimen.

HYDRONEPHROSIS

-After a period of time, the urine in the bladder can reflux into the kidneys, causing hydronephrosis -which is the stretching of the renal pelvis due to obstruction of the flow of urine from the bladder. -If the obstruction is not relieved, hydronephrosis can lead to kidney atrophy and chronic renal failure.

INDWELLING CATHETER 2

-After insertion, one lumen is used to inflate a balloon near the tip of the catheter with 5 to 30 mL of sterile water; the amount of water is dependent on the size of the balloon. -This inflated balloon sits at the junction of the bladder and the urethra, holding the catheter in place and helping to seal the exit from the bladder so that urine does not leak around the catheter. - Urine continually drains out of the bladder through the lumen of the catheter into a drainage bag that hangs low on the side of the patient's bed. -Indwelling catheters are inserted when the patient will need urine drainage for 1 or more days.

ENTEROBACTERIA

-Approximately 80% of UTIs are caused by bacteria from the bowel,

FEMALE PERINEAL ANATOMY

-Before you begin the procedure of inserting a catheter, you will need to examine the patient's perineal anatomy. -The female urinary meatus often resembles a small dimpling of the tissue, almost like a tiny slit or crease, rather than the easily detectable opening that you will see in the manikin in the skills laboratory. -The urinary meatus is generally located just below the clitoris, midway between the clitoris and the vaginal opening. - In some elderly females, you may find the urinary meatus at the edge of or slightly inside the vaginal opening. -A lack of hormones causes the tissue to atrophy, or shrink. -This results in pulling the urinary meatus into the vaginal opening, making it more difficult to access with a catheter. -In certain circumstances, you may find that you are unable to separate the female patient's legs due to severe contractures or other conditions. In these instances, a possible alternative may be to insert the catheter while the patient is lying on her side. -Turn the patient to the lateral position and view the urinary meatus from that angle before you prepare to insert the catheter. Patients who have long-term indwelling catheters may be easier to catheterize from this position.

ASSESSING KIDNET FUNCTION AND FAILURE

-Blood urea nitrogen (BUN) results from the breakdown of protein by the body. -The normal levels of BUN are 8 to 21 mg/dL in adults. -Abnormal elevations in BUN may reflect infection or some degree of renal impairment. -Creatinine is a waste product excreted by the kidneys. -The normal level of creatinine in the blood is 0.6 to 1.21 mg/dL in an adult male and 0.5 to 1.11 mg/dL in an adult female. -An increase in creatinine in the blood usually indicates decreased or impaired renal function. -A HCP can use the serum creatinine level in a formula with age, gender, and race to determine the estimated glomerular filtration rate (eGFR). This helps to determine the stage of renal disease that a patient is in. -A GFR less than 60 mL per minute when tested over 3 months indicates mild to moderate loss of kidney function. -A GFR less than 15 mL per minute indicates renal failure.

INDWELLING CATHETER

-DOUBLE-LUMEN CATHERTER -FOLEY CATHETER -EMPTIES BLADDER, The catheter will remain in the bladder, usually for a few days, and drain the urine on a continuous basis. -To relieve acute urinary retention or urinary obstruction -To obtain accurate urine output measurements in severely ill patients -To help prevent urine contact with an open wound in the sacral or perineal area -To prevent complications during or after certain surgeries, such as urologic or abdominal surgeries -To make the patient more comfortable at the end of life -If the obstruction is due to an enlarged prostate, a Coudé catheter may be the best choice -If the catheter cannot be advanced into the bladder at all, a health-care provider may have to insert a suprapubic catheter. Once the suprapubic catheter is inserted, the catheter is advanced about an inch into the bladder, and the balloon is filled with 5 mL of sterile water to hold it in place.

CONDOM CATHETERS

-EXTERNAL CATHETERS - not inserted into the bladder through the urethra, so they pose less of a risk for causing a UTI. -Most condom catheters are held in place with a double-sided adhesive strip applied to the penis. -It is important to apply the adhesive strip in a spiral. This prevents the strip from encircling the penis and potentially interfering with circulation. -It also is important to keep the foreskin in place when applying a condom catheter to an uncircumcised male patient.

URINARY DRAINAGE BAGS

-Empty the catheter bag every 8 hours or when it is full and document the amount in the medical record. -When emptying the bag, do not touch the drainage spout to any surfaces and wipe it with an alcohol swab before closing the spout. -Always empty urine into a graduated container to obtain an accurate measurement. Safety: Each patient must have his or her own graduated container for measurement. Sharing these containers among patients can lead to cross-contamination and increase the incidence of CAUTIs. -Maintain the drainage bag below the level of the bladder at all times. If the bag is elevated, the tubing should be clamped first to prevent urine in the tubing from flowing back into the bladder, potentially causing a UTI. -Keep the tubing free of kinks and coils. -Hang the drainage bag on a moveable part of the bed; it should not lay on the floor. Avoid hanging it on the bed rails, however, because it could be raised above the level of the bladder when the rails are raised.

BLADDER TRAINING

-Ensure that the patient is taking in adequate amounts of fluid, at least 64 ounces per day, to help maintain a healthy urinary tract and facilitate the elimination of waste. -Teach patients to avoid caffeinated beverages and to drink more during the day and less in the evening to prevent nighttime incontinence. -Offer fluids throughout the day, avoiding a large volume of fluid all at one time. Find out which fluids the patient prefers and offer an 8-ounce glass of fluid every 2 hours. -Assist the patient to the bathroom or offer a bedpan every 2 hours and assess the patient frequently for incontinence. If the patient has been incontinent between toileting, decrease the length of time between offering the bedpan or assistance to the bathroom. -Most people void in the morning, after meals, and before bed. Try to mimic the patient's normal voiding patterns -Safety: Clean the skin as soon as urinary incontinence is detected. When urine is left on the skin, the liquid portion evaporates and the chemicals left behind can cause skin irritation and skin breakdown. -indwelling urinary catheters are not placed for long-term urinary incontinence because they can lead to UTIs, sepsis, urethral strictures, prostatitis, and the potential development of bladder cancer.

CRYSTALS

-Few/negative -Positive=Renal stones

KEGEL EXERCISE INSTRUCTIONS

-Have the patient lie supine. -Have the patient place the hands on the lower abdomen to ensure that the abdominal muscles stay relaxed. -Tell the patient to tighten the pelvic floor muscles (the muscles that stop the flow of urine or prevent you from passing gas) without tightening the abdominal or thigh muscles. -Encourage the patient to hold the contraction for 5 to 10 seconds and then relax for 5 to 10 seconds. The patient should perform 40 to 60 exercises spread throughout the day. -Advise the patient to not perform the exercises while urinating because it can cause urinary retention.

PYELONEPHRITIS

-INFECTION IN KIDNEY -which can cause renal scarring and eventually lead to loss of kidney function.

CYSTITIS

-INFECTION IN THE URINARY BLADDER -If the infection is left untreated, it can travel from the bladder up the ureters and into the kidneys

TROUBLESHOOTING LOW OUTPUT

-If no urine is collecting in the drainage bag, palpate the urinary bladder above the pubic bone to assess for a full bladder. -Check for kinks in the catheter tubing. -Ensure that the patient is not lying on the catheter or drainage bag tubing. -Manipulate the drainage bag tubing so that the urine flows in a downward manner by gravity. -If the tubing is looped downward, urine will pool and back up because it cannot run uphill. -Have the patient change positions and see if the bladder will empty. -If the bladder feels distended (evidenced by palpating a firm area above the pubic bone), it is appropriate to perform a bladder scan. It is possible that the catheter is blocked by sediment or mucus.

POLYURIA

-Increased urinary output, or polyuria, is defined as output greater than 3,000 mL per day. -It can be caused by excessive fluid intake or by the consumption of alcohol, which affects the kidney's ability to reabsorb water. -Certain medications, such as diuretics, or "water pills," increase urine production.

CONTINOUS BLADDER IRRIGATION

-Irrigation fluid in large bags is hung from an IV pole, and the tubing is aseptically attached to the third lumen of the three-way catheter. -The irrigation fluid runs continuously at a slow rate to wash out blood and prevent clots from forming. If the urine in the collection bag becomes red or clots are evident in the tubing, increase the rate to flush them out. -Safety: Assess for fluid return into the drainage bag frequently. It is possible for a blood clot to clog the urine drainage lumen, blocking urine and irrigation fluid from leaving the bladder. This is extremely important because irrigation fluid continues to flow into the bladder via the irrigation lumen, filling the bladder fuller and fuller. This can result in overdistention of the bladder and could potentially rupture the bladder if the urine lumen remains clogged. -To correctly calculate output with a continuous bladder irrigation, you must subtract the amount of irrigation solution instilled from the amount of fluid in the urinary drainage bag. -For example, if 750 mL of saline was instilled during irrigation and a total of 1,000 mL of fluid has collected in the drainage bag, the amount of urine output would be 250 mL because you subtracted 750 from 1,000.

PROTEIN

-Less than 20 mg/dL=Increased -Decreased renal function, some drugs, contamination with vaginal secretions

RBCs

-Less than 5 -Increased number=Damage to renal tubules, tumors, renal calculi, or infection

WBCs (leukocytes)

-Less than 5 -Increased number=Urinary tract or vaginal infection

GLUCOSE

-Negative -Positive=Diabetes mellitus, Cushing's syndrome, liver and pancreatic disease

KETONES

-Negative -Positive=Uncontrolled diabetes mellitus, pregnancy, carbohydrate-free diet, starvation

RBC CAST

-Negative -Positive=Upper UTIs

NITRITES

-Negative -Present=Infection

LEUKOCYTE ESTERASE

-Negative -Present=Pyuria

WBC CASTS

-Negative -Present=Upper UTI

URGE INCONTINENCE

-OVERACTIVE BLADDER -the inability to keep urine in the bladder long enough to get to the restroom. -Normally, most people void five to six times a day. -The patient may have urine leakage because of the inability to get to the bathroom quickly. -This type of incontinence is caused by bladder spasms or contractions that lead to involuntary passing of urine. -Triggers that may lead to urge incontinence include the sound of running water, drinking liquid, or placing your hands in warm water. -Urge incontinence is often caused by a UTI, but many times the cause is not known. -Muscle toning and strengthening exercises are sometimes successful treatments for urge incontinence.

ASSISTING WITH TOILETING

-Offer the opportunity to use the bathroom or bedpan before and after meals and at bedtime. Male patients may use a urinal for voiding. Some men find it difficult to void while sitting or lying in bed. If allowed, the male patient may stand at the bedside to void into the urinal. -Use a fracture pan, which is smaller and flatter, for patients who have had a hip or back surgery. The pan slips more easily under the buttocks and does not require that the patient be rolled from side to side. -A fracture pan may also be used for patients who are very thin or if a regular bedpan causes back discomfort. In that situation, the patient may be rolled from side to side to place the fracture pan -Provide patients with privacy and avoid rushing them. -Offer patients the opportunity to perform hand hygiene after toileting. -Patients who are unable to ambulate to the bathroom will use a bedside commode. A bedside commode is a portable chair with a toilet seat and collection bucket beneath it, which is removed for cleaning. -Patients with orders for bedrest are not allowed to be out of the bed to go to the bathroom or to use a bedside commode. These patients will need to use a bedpan for elimination

DYSURIA

-Painful or difficult urination -Urination should not burn, and the patient should have voluntary control over the starting and stopping of the stream of urine. -Burning during urination may be indicative of UTI or bladder or urethral inflammation.

SUPRAPUBIC CATHETER

-Placed after trauma or surgery to the urethra or if an indwelling catheter cannot be inserted into the bladder. -The physician makes a small incision above the pubic bone, passes an instrument through the abdominal wall and into the bladder, and then places the catheter. -This procedure requires that the patient be given mild sedation or a local anesthetic.

PERFORMING A URINE DIPSTICK

-Read the manufacturer's instructions before performing the test. -Check the expiration date on the bottle of test strips. -Put on clean gloves for the test. -Remove one strip from the bottle and recap the bottle immediately to prevent contamination of other strips. -Dip the test strip into the urine and begin timing. Tap against the side of the cup to remove excess urine. -Hold the strip next to the bottle label, lining up the strip's small colored square pads to the corresponding ones on the bottle label. -At each specified time, read the appropriate colored pad and note the results.

MEASURING INTAKE AND OUTPUT

-Remember that the minimum acceptable output is 30 mL per hour, or 240 mL in 8 hours - When intake is greater than output, the patient is at risk for fluid overload. -When output is greater than intake, the patient is at risk for fluid deficiency or dehydration. -To measure urine output of an ambulatory patient, place a specimen pan underneath the front rim of the toilet or bedside commode to catch the urine. The inside of the specimen pan is marked in milliliter increments

STRAIGHT CATHETERS

-SINGLE-LUMEN CATHETER -for a patient who is unable to fully empty his or her bladder and you have found residual urine in the bladder using a bladder scan, -is a single tube with holes at the end. It may be made of red rubber, clear plastic, or silicone. -Straight catheters are also used by patients who must catheterize themselves on a regular basis to empty the bladder. -The health-care provider may or may not also order a sterile specimen from the bladder for a UA or culture and sensitivity testing. This is also sometimes called an in-and-out catheterization, indicating that the catheter does not remain in the bladder. -In the hospital setting, you will use a sterile catheter insertion kit and a sterile straight catheter every time you insert a catheter.

COLOR AND CLARITY

-STRAW-COLORED & CLEAR W/O SEDIMENT -the darker yellow the color, the lower the patient's hydration level. As dehydration worsens, the urine color may become dark yellow and then amber. -Urine can be cloudy, or have increased turbidity, due to the presence of fat globules, red or white blood cells, or bacteria, as well as due to sitting at room temperature for a long period.

COLOR AND APPEARANCE

-Straw-colored to pale yellow Lighter or totally clear Increased fluid intake, diabetes insipidus -Dark yellow Concentrated from decreased fluid intake or dehydration Medications and diet can also affect the color of urine -Clear Cloudy or increased turbidity Phosphate precipitation from setting, blood, epithelial cells, pus, fat droplets, bacteria, RBCs, WBCs -Milky=Pus, fat globules -Red or reddish-brown=Blood, sulfa drug Bright orangey-red=Pyridium (anesthetic drug for urinary burning) -Yellowish- or greenish-brown=Bile in urine -Green=Pseudomonas infection of urinary tract

CARING FOR AND CHANGING A SUPRAPUBIC CATHETER

-Suprapubic catheters may be required for long periods of time if the urethra cannot function normally. -Dressings around the insertion site are changed using sterile technique to prevent the introduction of pathogens directly into the bladder. -The tract from the bladder through the abdominal wall heals and forms a tunnel that the catheter is inserted through. -Suprapubic catheters that are in place for long periods usually are changed as needed. It is no longer recommended to change any catheters at routine times, such as every 30 days -You will still use a sterile catheter kit, sterile gloves, and the correct size of sterile catheter. The patient is positioned on his or her back, and the drapes are applied to the lower abdomen -Only 3 to 5 mL of sterile water is placed in the balloon, so that amount will be withdrawn before an existing catheter is removed and replaced by a new one. -Once the existing catheter is removed, clean around the suprapubic tract with the sterile swabs provided in the kit. -Gently insert the lubricated catheter only 1 to 3 inches at a 10- to 30-degree angle to follow the suprapubic tract into the bladder. -Insert 3 to 5 mL of sterile water into the balloon and tug very slightly to seat the catheter in the bladder opening.

SYMPTOMS OF UTI

-Symptoms of UTI include dysuria, urinary frequency, urgency, nocturia, low abdominal pain, and incontinence. If the patient has fever, chills, malaise, nausea, vomiting, and flank pain, the infection has most likely spread to the kidneys, causing pyelonephritis

THREE-WAY CATHETERS

-TRIPLE-LUMEN CATHETER -ALCOCK CATHETER -is inserted through the newly cleared urethra and into the bladder to allow for irrigation of the bladder. -Because cutting has occurred, it is normal for blood and blood clots to pass through the three-way catheter and into the urinary drainage bag. -The goal of nursing care after this procedure is to prevent any blood clots from obstructing the flow of the irrigation fluid into the bladder and back out again.

LONG-TERM CARE AND CATHETERIZATIONS

-The Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services states that only residents with appropriate justification should have indwelling urinary catheters. -Appropriate use includes residents who have intractable urinary retention, stage 3 or stage 4 pressure injuries, terminal illness, or severe impairment such that positioning and clothing changes are uncomfortable or are associated with intractable pain.

Payment of Costs Related to Hospital-Acquired Urinary Tract Infections

-The Centers for Medicare and Medicaid Services has determined that its insurance plans will no longer pay for any costs associated with catheter-related hospital-acquired infections. -If a patient acquires a UTI after a urinary catheter is inserted in a hospital setting, the facility will not be paid for the costs of antibiotics, extra hospital days, or any other associated expenses. -Your technique must be excellent when inserting urinary catheters and caring for patients with them.

AMOUNT

-The normal range of urine production is 1,000 to 3,000 mL in a 24-hour period. -The acceptable minimal amount of urinary output per hour is 30 mL. -For a person to have a balanced intake and output (I&O), there should be within a difference of approximately 300 to 500 mL in urine output compared to the total intake.

ILEAL CONDUIT

-The ureters are attached to a section of the small intestine that has been used to create a pouch and stoma. -Urine drains continuously from the stoma. The patient wears an appliance over the stoma to collect the urine. -One of the greatest challenges with an incontinent urinary diversion is skin care. -If the patient has a problem with irritation or skin breakdown, an enterostomal therapist or wound care nurse can recommend protective skin wipes or an ostomy powder to help protect the skin.

MALE PERINEAL ANATOMY

-The urethra of the male may open on the dorsum of the penis rather than at the tip of the penis, a condition known as epispadias. -If the urethral meatus is located on the underside of the penis, the condition is termed hypospadias. -For patients who have not been circumcised, you must retract the foreskin, or move it back from the glans, during catheterization. -Safety: It is extremely important that you replace the foreskin to its original position after you have inserted the indwelling catheter. Failure to do so can cause constriction of blood flow to the glans penis, causing swelling and possible necrosis. -If the patient has an enlarged prostate, you may meet resistance when you try to insert the catheter. If this occurs, twist the catheter slightly as you attempt to advance it. Sometimes this will be adequate to allow the catheter tip to enter the portion of the urethra that passes through the enlarged prostate. -If that does not advance the tip beyond the prostate gland, the procedure may need to be attempted again using a Coudé catheter.

URINARY INCONTINENCE

-This inability to control the passing of urine

URINALYSIS

-This test is done to determine the presence of renal calculi, a UTI, a malignancy, and diseases affecting the kidneys. -Safety: When you obtain a specimen, transport it to the laboratory immediately or store it in a refrigerator. Urine that is left standing longer than 1 hour starts to break down, and the test becomes ineffective.

pediatric considerations for urinary care

-UTI is second only to respiratory infections in children. -Poor feeding, vomiting and diarrhea, and sleeplessness may occur. -UTIs occur more often in girls than boys. Girls should be taught from a young age to wipe from front to back. -If a young girl does have recurrent UTIs, instruct her parents to have her shower rather than bathe and avoid bubble baths, which can lead to UTIs. -To obtain a urine specimen from a child who is not yet toilet trained, you may use a sterile plastic urine collector bag with an adhesive patch placed over the genitals. -Another type of device for collecting a urine specimen from a child may have the catheter extending from a test tube-like collection device.

3 WASTE PRODUCTS THAT MUST BE REMOVED

-Urea, which results from amino acid metabolism -Uric acid, which results from breakdown of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA) -Creatinine, which is the waste product of muscle metabolism

CATHETER SIZE

-Urinary catheters come in different sizes gauged by measuring the outer diameter of the catheter: -the larger the number, the larger the catheter. -The size is denoted with a number followed by French (Fr), which is the scale of measurement for urinary catheters. -A child may need a size 8 French, while an adult may need a size 14 or size 16 French. -When a patient in long-term care or home care has had an indwelling catheter for several years, it may be necessary to use even larger sizes, such as 20 or 22 French, because the urethra and cystourethral junction stretch over time. -Catheters also come in different lengths according to their purpose. -A 22-cm length would be appropriate for a female, while a 40-cm length would be appropriate for a male. -However, in most healthcare settings, a standard length of 40 cm is used. -Catheters also come with different sizes of inflatable balloons, ranging from 5 to 30 mL.

STRAIGHT CATHETERS 2

-Used only for insertion into the urinary bladder to obtain a sterile urine specimen or a one-time drainage of urine from the bladder. -It is aseptically inserted into the bladder through the urinary meatus, where either all the urine is drained or just enough urine for a specimen is obtained. -Then the straight catheter is removed.

Coudé Catheter

-Used specifically to accommodate an enlarged prostate in male patients. -It has a curved tip, allowing it to more easily pass through an enlarged prostate gland and enter the bladder.

NOCTURIA

-When a person wakes often during the night to urinate, -Occasional nocturia may be caused by ingesting large amounts of fluid in the evening. -If a patient has persistent nocturia, it may be due to an underlying disease process, such as heart failure, uncontrolled diabetes mellitus, a UTI, an enlarged prostate, or kidney disease.

DISCONTINUING CATHETERS

-You must have a healthcare provider's order to discontinue an indwelling catheter. -Upon removal of the catheter, it is important that you monitor for urinary retention, to determine if the patient has urinated within a maximum of 8 hours after the catheter was removed. -Be certain to document when the patient voids and how much is voided. -Safety: If a patient has not voided in the 8 hours after removing an indwelling catheter or has voided less than 240 mL, perform a bladder scan and notify the health-care provider. -You may then receive an order to insert a straight catheter to empty the bladder or to reinsert an indwelling catheter if the bladder scan reveals an excessive amount of residual urine.

FOCUSED ASSESSMENT

-You will also learn to monitor for edema, or swelling, due to fluid retention. Edema due to kidney problems may be found in the hands, legs and feet, sacrum, and face. -The quickest way to assess whether or not a patient is retaining water is to perform daily weights, at the same time each day, with the same scales, and with the patient wearing approximately the same amount of clothing -The frequency of urination also is important. As mentioned earlier in the chapter, the average individual urinates four to six times per day and does not routinely get up during the sleeping hours to void. -Patients who urinate with increased frequency may be exhibiting symptoms of a UTI, bladder inflammation, or diabetes mellitus.

CATHETER CARE

-You will provide perineal and catheter care together at least once a shift and any time the catheter becomes contaminated by a bowel movement to prevent UTIs. -After cleansing the perineal area thoroughly, use clean water and a clean washcloth to perform catheter care. -Hold the catheter in your gloved hand to prevent traction on the tubing as you clean the catheter. -Using perineal wash or a disposable washcloth, clean the catheter with downward strokes from the insertion site toward the catheter bag. -Safety: Always use downward strokes as upward strokes encourage the movement of microorganisms into the bladder.

ORTHOTOPIC BLADDER SUBSTITUTION

-a part of the intestines is used to make a new bladder. -The ureters drain into it, and the urethra drains the substitute bladder. -The patient is able to void through the urethra but may experience incontinence and may have to perform self-catheterization intermittently

CONTINENT UROSTOMY

-a pouch is created from the intestine, the ureters empty into the pouch, and a nipple valve is constructed -The patient performs self-catheterization intermittently during the day to empty the pouch

URINE IS MADE UP

-approximately 95% water, with the remaining 5% being the solutes that are dissolved in the water, such as mineral salts and nitrogenous waste products. -The kidneys eliminate these waste products before the blood levels rise high enough to be damaging, or toxic, to the body.

ODOR

-have a very mild odor described as slightly aromatic. -Other odors, such as a sweet or fruity smell, a strong ammonia-like smell, or a foul odor, are abnormal findings.

TREATMENT OF UTI

-includes rest, -increased fluid intake, -antibiotics, and -urinary analgesics. T -he treatment of pyelonephritis may include hospitalization for IV antibiotics. -Patients are encouraged to drink cranberry juice or take cranberry extract tablets, which inhibit bacteria from adhering to the urinary tract. -As a general rule, patients should consume 64 ounces of noncaffeinated fluid a day unless contraindicated.

URINARY CATHETER

-is a tube usually made of rubber, plastic, latex, polyvinyl, or silicone that is inserted through the urethra into the bladder. -It may be inserted and then quickly removed after the bladder is emptied, as in the case of a straight catheter, or it may remain in place when an attached balloon is inflated, anchoring it in the bladder.

SEDIMENT

-is any substance that settles to the bottom of a liquid. -Components that may produce urine sediment include uric acid, bacteria, mucus, and phosphates.

URINARY TRACT INFECTION

-is caused by the presence of pathogens within the urinary tract. -Any structure in the urinary tract may become infected, and the infection can spread from one structure to another. -UTIs are more commonly seen in women than men because of the close proximity of the urethral opening to the anus -The body's defense mechanisms help prevent UTIs. The pH of urine is acidic to help kill bacteria. -Vaginal secretions also are acidic, which inhibits microorganisms from the rectum from migrating into the bladder. -Sexual intercourse, the use of diaphragms, and the use of spermicidal gels also can increase the incidence of UTIs. -The presence of nitrites and leukocyte esterase indicates a UTI. Nitrites can only be present if there are bacteria in the urine. -A midstream clean-catch or straight catheter urine specimen may also be obtained for the purpose of performing a UA to diagnose a UTI.

OLIGURIA

-is defined as urinary output of less than 30 mL per hour. -It can be caused by decreased fluid intake, dehydration, illness, urinary obstruction, or renal failure. -Oliguria also may be caused by hemorrhage or by severe loss of body fluids.

ANURIA

-is the absence of urine production. -It can be due to a temporary illness or urinary tract obstruction, or it can be a symptom of a serious underlying condition, such as kidney failure. -In more serious illnesses that shut down kidney function, the physician will order dialysis for the patient.

TOTAL INCONTINENCE

-is the loss of urine with no warning. -In this situation, the person is unaware of the need to void and makes no effort to get to a bathroom.

DIALYSIS

-is the process of using a machine to filter waste products and salts and to remove excess fluid from the blood. - This treatment may be temporary or long term depending on the cause of the anuria.

URINARY DIVERSIONS

-means that the urine is eliminated by an alternative route rather than traveling through the bladder. -These diversions may be established when there has been trauma to the bladder or the bladder has been removed as a result of bladder cancer. -Occasionally, the ureters or bladder did not form correctly before birth, leading to a congenital condition requiring a urinary diversion.

OVERFLOW INCONTINENCE

-occurs when the bladder is distended due to an obstruction, which prevents the bladder from emptying normally. -Some urine may then leak past the blockage, causing overflow. -In men, the most common cause of this obstruction is an enlarged prostate gland.

NEUROPATHIC INCONTINENCE

-occurs when the nerves that control the bladder and surrounding structures are not getting the message to the brain that the bladder is full.

FUNCTIONAL INCONTINENCE

-occurs when the person is unable to reach a bathroom to urinate. -This may be due to the unavailability of bathroom facilities or the person's inability to get on the toilet before urination occurs

STRESS INCONTINENCE

-occurs with increased abdominal pressure, which causes urine to leak out of the bladder. -SEEN MORE IN WOMEN -Increased abdominal pressure can be caused by coughing, laughing, sneezing, vomiting, and heavy lifting or straining—anything that elicits a "bearing down" effect. -Factors that may contribute to the development of stress incontinence include vaginal births, previous pelvic or vaginal surgery, genetics, hormone levels, and chronic medical conditions. -When pelvic floor muscles become weak, they do not support the bladder and urethra, leading to urine leakage.

NURSING INTERVENTIONS TO MANAGE INCONTINENCE

-teaching the patient to perform Kegel exercises, which will strengthen and tone the pelvic floor muscles. -Encourage women to engage in a moderate exercise program on a regular basis to help decrease the incidence of incontinence.

TIMED URINARY COLLECTION

-the most common timed urine specimen is a 24-hour urine collection. -This type of specimen is helpful in evaluating kidney function by measuring the levels of various components in the urine, especially protein levels. -Ask the patient to void and discard the urine. This ensures that the 24-hour specimen begins with the patient having an empty bladder. -Note the exact time that the urine is voided and discarded. This begins the 24-hour period. -Post signs in the patient's room and on the door stating that the 24-hour urine collection is in progress. -Include the date and time the collection started and the date and time it is to end. -Collect every drop of urine that is voided during the next 24 hours, and pour it into the specified large-volume container. This container is kept on ice or refrigerated to prevent the urine from decomposing. -If the patient has an indwelling urinary catheter, place the collection bag in a basin with ice. -Empty the collection bag into the 24-hour urine container. -If any urine is discarded during the 24-hour period, the entire specimen must be restarted. -Exactly 24 hours after the collection began, ask the patient to void one last time and add the urine to the collection container. Then take the 24-hour specimen to the laboratory for testing. Remove the signs, and inform the patient that the collection is completed.

RESIDUAL URINE

-urine that remains in the bladder after the patient voids. -It may be caused by bladder outlet obstruction or problems with the detrusor muscle's contractility. -Normally, the maximum amount of urine left in the bladder after voiding is 100 mL.

NEUROGENIC BLADDER

-where the nerves to the bladder have been permanently damaged. -The patient cannot control the nerves that cause the bladder to empty. -The patient or a caregiver must insert a straight catheter to empty the patient's bladder several times per day, usually about every 4 hours.

BACTERIA

Bacteria=Negative +1 to +4 TNTC (too numerous to count) -UTI

CHARACTERISTICS OF URINE

COLOR, CLARITY, AMOUNT, ODOR

RENAL CALCULI

KIDNET STONES

ODOR

Slightly aromatic=Strong fruity odor Diabetes mellitus, starvation, and dehydration all cause formation of ketone bodies -Fetid or foul odor=Escherichia coli infection -Maple syrup odor=Maple syrup urine disease -Fecal odor=Rectal fistula

HEMATURIA

blood present in urine

MIXED INCONTINENCE

is diagnosed when a patient experiences both stress and urge incontinence

SPECIFIC GRAVITY

is the result of comparing the weight of a substance with the weight of an equal amount of water. -The normal specific gravity for urine is 1.005 to 1.03. -When the specific gravity is high, it means that the urine is more concentrated. A high specific gravity can be the result of dehydration, hemorrhage, or diabetes mellitus. -When the specific gravity is low, the urine is more dilute.A low specific gravity may be caused by excessive fluid intake or impaired kidney function.

VOID

to urinate= MICTURATE