Unit 11, Chapter 46 - Urinary Elimination

Describe assessment of patient with a Foley catheter.

- Hygiene (especially after BM) - many institutions require catheter care a minimum of every 8 hours - make sure drainage bag is empty when ½ full. - expect continuous drainage into bag if not, look for kinks or blockage - monitor drainage system to prevent pooling of urine inside tubing and keep bag below level of bladder - make sure catheter isn't leaking from catheter, tubing or connections - assess urine character and amount of urine in drainage system - evaluate patient for s/s of UTI - pain, burning, discomfort, irritation - assess self-care skills - have patient discuss feelings regarding permanent changes in elimination - assess external genitalia for inflammation/infection - assess urinary meatus for catheter related damage, inflammation and discharge - early detection of trauma Pgs. 1111, 1121, 1127, 1139

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Start a scheduled toileting program. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.

Answer: 2

Describe techniques used in providing bedpan, urinal or commode.

A strategy to promote relaxation and stimulate bladder contractions is to help patients assume the normal position for voiding. Depending on the patient, more assistance is needed (ie, placing the penis in the urinal). Use sensory stimuli and provide privacy to promote relaxation and stimulate bladder contractions. Bladder exercises help to improve pelvic muscles, which reduces stress incontinence and improves bladder emptying. Pg. 1119

Mrs. Rantz complains of leaking urine when she coughs and laughs. This is known as: 1. Urge incontinence 2. Stress incontinence 3. Reflex incontinence 4. Functional incontinence

Answer: 2

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.

ANS: B Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.

A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.

ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.

When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein

ANS: A Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."

ANS: A Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL

ANS: A Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.

A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.

ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.

What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar

ANS: A The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.

A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria

ANS: A Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.

The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. c. Perineal care is often neglected by nursing staff. d. Bedpans and urinals are not stored properly and transmit infection.

ANS: B E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.

Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence

ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.

11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins

ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.

A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication

ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra

ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.

The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.

ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.

The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills

ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.

The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.

ANS: C Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.

Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."

ANS: C Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

Answer: 1, 4

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.

ANS: C Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.

The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.

ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.

Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

ANS: C Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.

To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.

ANS: C The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence

ANS: D Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.

The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.

ANS: D Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete.

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram

ANS: D Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.

A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.

ANS: D Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI. 2. Assess the intake and output from system. 3. Decrease the rate of the CBI. 4. Assess vital signs.

Answer: 2

When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.

ANS: D The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.

Describe key signs and symptoms of urinary retention.

Acute or rapid: - Feelings of pressure, discomfort/pain, tenderness over the symphysis pubis, restlessness and sometimes diaphoresis (sweating) - Patients may have no urine output over several hours and in some cases experience frequency, urgency, small-volume voiding or incontinence of small volumes of urine Chronic: - slow, gradual onset, decrease in voiding volumes, straining to void, frequency, urgency, incontinence and sensations of incomplete emptying Pg. 1103

Identify nursing interventions to promote micturition and reduce episodes of incontinence.

Adequate lighting in bathroom. Individualized toileting program. Mobility aides (raised toilet set, toilet grab bars) Elastic waist pants without buttons or zippers Call bell always in reach Avoid bladder irritants Instruct patient in pelvic muscle exercises, as directed by healthcare provider. Monitor for s/s of UTI or urinary retention. Pg. 1104 Table 46-1

Ms. Hathaway has a UTI. Which of the following symptoms would you expect her to exhibit? 1. Dysuria 2. Oliguria 3. Polyuria 4. Proteinuria

Answer: 1

What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

Answer: 1

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

Answer: 1, 3, 4

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing diagnosis? 1. Implement the "as-needed" order to irrigate the catheter. 2. Assess the catheter and drainage tubing for obvious occlusion. 3. Notify the health care provider immediately. 4. Assess the vital signs and intake and output record.

Answer: 2

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter further.

Answer: 2

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary drainage bag 3 to 4 times daily with antiseptic solution. 2. Hanging the urinary drainage bag below the level of the bladder. 3. Emptying the urinary drainage bag daily. 4. Irrigating the urinary catheter with sterile water.

Answer: 2

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

Answer: 2, 3

The nurse is working in the radiology department with a patient who is having an intravenous pyelogram. Which of the following complaints by the patient is an abnormal response? 1. Frequent, loose stools 2. Thirst and feeling "worn out" 3. Shortness of breath and audible wheezing 4. Feeling dizzy and warm with obvious facial flushing

Answer: 3

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.

Answer: 3

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine. 2. Slightly cloudy urine. 3. Light pink urine. 4. Dark amber urine.

Answer: 3

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

Answer: 3

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass urine?

Answer: 3

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube. 2. Shaving the pubic area so hair does not adhere. 3. Washing with soap and water before applying the condom-type catheter. 4. Applying tape to the condom sheath to keep it securely in place.

Answer: 3

The urinalysis of Ms. Hathaway reveals a high bacteria count. Ampicillin is prescribed for her UTI. The teaching plan for the prevention of a UTI should include all of the following except: 1. Drink at least 2000 mL of fluid daily. 2. Always wipe the perineum from front to back. 3. Drink plenty of orange and grapefruit juices. 4. Explain the possible side effects of medication.

Answer: 4

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9

Describe the guidelines for nursing interventions to maintain normal elimination.

Box 46-1 Pg. 1104

Identify the most common causes of UTIs.

E. coli is most common causative pathogen. Risk increases in the presence of an indwelling catheter, any instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence and poor perineal hygiene practices. CAUTIs are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays and increased hospital costs. Pg. 1103, 1105

Describe outcome criteria for patients with urinary problems.

Evaluate for changes in the patient's voiding pattern and/or presence of symptoms such as dysuria, urinary retention and UI. Evaluate patient/caregiver compliance with the plan such as toileting according to the schedule or the number of incontinent episodes. Actual outcomes are compared with expected outcomes to determine success or partial success in achieving these outcomes. Pg. 1127

Identify nursing diagnosis for patients with urinary elimination problems from established nursing diagnosis list.

Functional urinary incontinence Stress urinary incontinence Urge urinary incontinence Reflex incontinence Risk for infection Toileting self-care deficit Impaired skin integrity Impaired urinary elimination Urinary retention Pg. 1113

Describe factors influencing urination.

Growth and development Sociocultural factors Psychological factors Personal habits Fluid intake Pathological conditions Surgical procedures Medications Diagnostic examinations Pg. 1102 Box 46-1

Explain the procedure for application and removing a condom catheter.

Identify patient with two identifiers. Perform hand hygiene. Assess urinary elimination patterns, patient's ability to empty bladder effectively, and degree of continence. Assess patient's mental status, knowledge about the procedure and ability to self-apply device. Explain procedure. Provide privacy by closing room door or bedside curtain. Raise bed to working height and lower side rail on working side. Prepare condom catheter (prescribed size and type), drainage bag and tubing. Help patient to a supine or sitting position. Place bath blanket over upper torso; fold a sheet over lower torso so only penis is exposed. Apply clean gloves; provide perineal care and dry thoroughly. If patient is uncircumcised, ensure that the foreskin is in the normal non-retracted position. Do not apply barrier cream and make sure that any remaining adhesive is removed. Assess penis for erythema, rashes and/or open areas Condom catheters can only be applied to intact skin. Clip hair at baseline of penile shaft if necessary. Don't shave the pubic area. Some manufactures provide hair guard, which is placed over the penis before applying the device. An alternative to a hair guard is to tear a hole in a paper towel, place it over the penis, and remove after application of the device. Apply condom catheter. With nondominant hand, grasp penis along shaft. With dominant hand, hold condom sheath at tip of penis and smoothly roll sheath onto penis. Allow 2.5 to 5 cm (1 - 2 inches) of space between tip of penis and end of catheter. Secure condom catheter according to manufacturer directions. Connect drainage tubing to end of condom catheter. Be sure that the condom is not twisted. Connect catheter to large-volume drainage bag or leg. Help patient to a safe, comfortable position, lower bed, and place side rails accordingly. Dispose of contaminated supplies, remove gloves, perform hand hygiene. Inspect penis with condom catheter in place within 15 to 30 minutes after application for any swelling, discoloration or discomfort. Observe for patency of urinary drainage system, characteristics of urine, condition of penis, and proper placement of condom catheter. Remove and reapply daily following the previous steps unless an extended-wear device is used. For removal, wash the penis with war, soapy water and gently roll the sheathe and adhesive off the penile shaft. Pg. 1125 Box 46-12

Recognize normal and abnormal characteristics of urine.

Inspect urine for color, clarity and odor. Normal color ranges from pale straw color to amber, depending on concentration. Blood in urine is not a normal finding, unless female is on menstrual cycle. Various medications and foods change the color and odor of urine (asparagus - odor, phenazopyridine - bright orange color) Dark amber urine - high concentrations of bilirubin in patients with liver disease. Normal urine appears transparent at time of voiding. Becomes cloudy after standing several minutes in container. Thick, cloudy urine - bacteria and WBCs may be present Urine has characteristic ammonia odor. Foul odor may indicate UTI. Pg. 1111, 1112

Explain procedure for collecting, measuring and documenting urinary output and oral intake.

Intake measurements need to include all oral liquids and semi-liquids, enteral feedings, and any parenteral fluids. Output measurements need to include not only urine but any fluid that leaves the body that can be measured such as vomit, gastric drainage tubes and wound drains. Urine volume is measured using receptacles with volume measurement markings. After patient voids in bedside commode, bedpan or urinal, when urine is emptied from a catheter drainage bag, urine can be measured using a graduated measuring container. A urine hat can be used for patient who voids in toilet. Catheterized patients may have a specialized drainage bag with a urometer attached for accurate hourly urine measurement. Pg. 1111

Review basic anatomy and physiology of the urinary tract.

Kidneys - nephrons - function unit of the kidneys that remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance - glomerulus - each nephron contains a cluster of capillaries called the glomerulus; filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes; large proteins and blood cells don't filter through the glomerulus - proximal convoluted tubule, loop of Henle, distal tubule- approximately 99% of glomerular filtrate is resorbed into the plasma by the proximal convoluted tubule, the loop of Henle and the distal tubule Ureters - attached to each kidney pelvis and carries urinary waste to the bladder Bladder - a hollow, distensible, muscular organ that holds urine; expands as it fills with urine Urethra - urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus Pg. 1101 - 1103

Establish goals for identified urinary elimination problems.

Must include realistic and individualized goals along with relevant outcomes. A general goal is often normal urinary elimination; but sometimes the individual goal differs, depending on the problem. Pg. 1115

Identify assessments for urinary retention.

Palpate the bladder for smooth, rounded mass On inspection, may observe swelling or convex curvature of lower abdomen Patient may report tenderness or pain Further assessment with bladder scanner may be necessary Assess for incontinence or small volume voids, straining to void Pg. 1103, 1110, 1111

Identify the guidelines for bladder retraining.

Patients are given a toileting schedule on the basis of their diary of voiding and leaking and it's designed to slowly increase the interval between voiding. Patients are taught to inhibit the urge to void by taking slow, deep breaths to relax, performing five to six quick, strong pelvic muscle exercises (flicks) in quick succession, followed by distracting attention from bladder sensations. When the urge to void becomes less sever or subsides, only then should the patient start his or her trip to the bathroom. Pgs. 1126, 1127

Explain how to collect urine specimens for a timed test, clean catch and midstream.

Pg. 1112, 1128 Skills book pg. 150

Describe and demonstrate care of the closed drainage system for a Foley catheter.

Pg. 1140, 1141

Identify nursing interventions used to prevent catheter urinary infections.

Require use of evidence based "bundle" to perform all elements of care at one time along with completion of a checklist to ensure that each element is included in that care. Know institutions policies. Patients in acute care hospital should have urinary catheters inserted using aseptic technique with sterile equipment. Secure indwelling catheters to prevent movement and pulling on the catheter. Maintain a closed urinary drainage system. Maintain an unobstructed flow of urine through the catheter, drainage tubing and drainage bag. Keep the urinary drainage bag below the level of the bladder at all times. Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for the patient. Don't let the drainage spigot touch the receptacle. Before transfers or activity, drain all urine from the tubing into bag and empty drainage bag. Empty the drainage bag when ½ full. Perform routine perineal hygiene daily and after soiling using antiseptic wipes. Be sure to use a wipe to clean the length of the exposed catheter. Obtain urine samples using the sampling port. Cleanse the port with disinfectant. Use a sterile syringe/cannula. Quality improvement programs should be in place that alert providers that a catheter is in place and include regular educational programming about catheter care. Pg. 1122 Box 46-1

nocturia

awakened from sleep because of the urge to void

Compare and contrast common urinary alterations.

Urgency - overactive bladder, UTI, full bladder, inflammation or irritation of bladder Dysuria - UTI, inflammation of the prostate, urethritis, trauma to the lower urinary tract, urinary tract tumors Frequency - overactive bladder, UTI, high volumes of fluid intake, bladder irritants, increased pressure on the bladder Hesitancy - bladder outlet obstruction, anxiety Polyuria - high volumes of fluid intake, uncontrolled diabetes mellitus, diabetes insipidus, diuretic therapy Oliguria - fluid and electrolyte imbalance, kidney dysfunction or failure, increase secretion of ADH, urinary tract obstruction Nocturia - overactive bladder, bladder outlet obstruction, UTI, medications, cardiovascular disease Dribbling - bladder outlet obstruction, incomplete bladder emptying, stress incontinence Hematuria - tumors, infection, trauma to urinary tract, urinary tract calculi Retention - bladder outlet obstruction, absent or weak bladder contractility, side effects of certain meds Pg. 1110 Table 46-2

indwelling urethral catheter

a flexible, plastic tube inserted into bladder that remains there to provide continuous urinary drainage

cystoscopy

a procedure that allows provider to examine the lining of bladder and urethra; a hollow tube equipped with a lens is inserted through urethra and slowly advanced into bladder

condom catheter

a soft, pliable condom-like sheath that fits over the penis, providing a safe and non-invasive way to contain urine

retention

acute: suddenly unable to void when bladder is adequately full or overfull chronic: bladder does not empty completely during voiding and urine is retained in the bladder

Define micturition, voiding and urination.

all terms that describe the process of the bladder emptying

urgency

an immediate and strong desire to void that is not easily deferred

micturition

another term for urination; act of passing urine

When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

b. A urinary catheter. A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention

hematuria

blood in the urine

dysuria

burning or pain with urination

urinary incontinence

complaint of any involuntary loss of urine

total incontinence

continuous and total loss of urinary control and is the severest type of incontinence; causes either continuous leakage or periodic, uncontrolled emptying of the bladder's contents; bladder becomes incapable of storing any urine

oliguria

diminished urinary output in relation to fluid intake

glycosuria

excess of sugar in the urine, typically associated with diabetes or kidney disease

anuria

failure of kidney to produce urine

foley catheter

flexible tube passed through the urethra and into the bladder to drain urine; most common type of indwelling urinary catheter

urinary retention

inability to partially or completely empty the bladder

stress incontinence

involuntary leakage of small volumes of urine during increased abdominal pressure in the absence of bladder muscle contraction; result of weakness or injury to the urinary sphincter or pelvic floor muscles (trauma after childbirth, radical prostatectomy, weak pelvic floor muscles); underlying result: urethra can't stay closed as pressure increases in the bladder as a result of increased abdominal pressure

reflex incontinence

involuntary loss of urine occurring at somewhat predictable intervals when specific bladder volume is reached (R/T spinal cord damage)

urge incontinence

involuntary passage of urine often associated with a strong sense of urgency related to overactive bladder (caused by neuro problems, bladder inflammation or obstruction); in many cases bladder overactivity is idiopathic (cause unknown); caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine

overflow incontinence

involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate; may be a side effect of certain medications

enuresis

involuntary urination

incontinence

lack of voluntary control over urination or defecation

functional incontinence

loss of continence from causes outside the urinary tract; usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, or environmental barriers

pyuria

presence of white cells in the urine, usually indicating bacterial infection

urination

the discharge of urine from the body

voiding

the discharge of urine from the body; another way to say urination or micturition

proteinuria

the presence of abnormal quantities of protein in the urine, which may indicate damage to the kidneys.

catheter

tube placed through urethra into bladder to drain urine

polyuria

voiding excessive amounts of urine

frequency

voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours