Urinary Elimination CH 41

Special Circumstances

1. Assess: Is the wrong catheter currently in use for a patient needing a bladder irrigation procedure? Intervention: Change the catheter to the correct type. • A single-lumen catheter or straight catheter without a balloon can be used for intermittent bladder irrigation. • A double-lumen catheter may be used for: • Intermittent irrigation or • Continuous irrigation with a sterile Y-connector • A triple-lumen catheter is the best choice for closed continuous irrigation. 2. Assess: Have you observed bladder distention or the presence of clots, sediment, or mucus in the tubing? Intervention: Any of these factors may indicate clogged tubing, bleeding, or tissue sloughing. • Check whether output is greater than intake. • Check the tubing for patency. • Verify that the tubing is placed below the level of the bladder. • Milk the tubing, if doing so will not further irritate or damage fragile tissue: • Starting at the point at which the tubing exits the patient, squeeze the tubing and release it. • Repeat the process while moving along the tube, progressing downward from the patient toward the collection device. • Be careful not to tug on the catheter or dislodge it. • Milking may release a clot or blockage in the tubing. • An alcohol wipe on the outside of the tubing may augment this technique. 3. Assess: Is the patient experiencing bladder spasms or discomfort? Intervention: Check the temperature of the irrigation solution; cold solutions may cause spasms. 4. Assess: What should be done if the irrigation solution does not flow easily with gentle pressure during intermittent irrigation? Intervention: Reposition the syringe and check the catheter placement in the bladder.

Catheter Procedure:

1. If you are right-handed, work from the side of the bed closer to the patient's right side; if you are left-handed, work from the side of the bed closer to the patient's left side

24-Hour Urine Collection

A 24-hour urine collection usually is performed to determine the amount of creatinine cleared through the kidneys. This timed specimen also is used to measure levels of protein, hormones, minerals, and other chemical compounds in the urine. Creatinine clearance, which measures how well creatinine is removed from the blood by the kidneys, provides information about kidney function. Factors or conditions that may interfere with the accuracy of a 24-hour urine collection include failure to include some portion of the output, continuing the collection beyond 24 hours, spilling the specimen, inability to keep the specimen cool, and previous ingestion of certain foods or medications. Preparation is not required before initiation of a 24-hour urine collection. The time of the patient's first morning void is the best start time for the 24-hour specimen collection. The first voided specimen is not saved; all urine produced after the first (discarded) specimen is collected in a special opaque container and kept cool. At the completion of the 24 hours, the first voided specimen of the second day (if the collection was started in the morning) is included in the specimen, and the container is transported to the laboratory for analysis. Twenty-four-hour collections may be performed on an outpatient or inpatient basis.

Kidney, Ureter, and Bladder X-ray Study

A kidney, ureter, and bladder (KUB) study is a diagnostic x-ray image centered on the iliac crest, typically used to investigate gastrointestinal conditions such as a bowel obstruction or gallstones; it also can detect the presence of kidney stones. In addition, KUB studies are used to assess positioning of indwelling devices such as ureteral stents. A ureteral stent is an indwelling tube placed in the ureter, at a point between the kidney and the bladder. Stents are placed to prevent or treat obstruction of the urine flow through the ureter.

Abnormal Urination Patterns

Abnormal patterns of urination fall into several categories related to failure of the kidneys to produce or excrete more than 50 to 100 mL of urine in 24 hours ( anuria ), A reduced volume of urine typically greater than 100 and less than 500 mL in 24 hours ( oliguria ), Excessive production and excretion of urine ( polyuria ), Excessive urination at night ( nocturia ), Painful urination ( dysuria ), And blood in the urine ( hematuria ). Urinary incontinence , the inability to control urination, is prevalent, particularly in women, and can greatly impact quality of life. Urinary retention is the inability to empty the bladder fully and generally is caused by an obstruction or neurologic disorder, enlarged prostate gland, or infection, among other factors.

Ureters

After exiting the kidneys, urine is carried to the bladder by narrow tubes called the ureters. The ureter wall muscles continually tighten and relax, forcing urine downward. If urine is retained in the kidney or backflows from the bladder toward the kidneys, the patient becomes susceptible to kidney infections.

Life Span Urinary patterns change over the course of a lifetime.

Age • Full bladder control is attained between the ages of 3 and 5 years, although nighttime control may not occur until the age of 4 to 5 years. • Loss of muscle tone in the bladder in older adults contributes to incontinence and frequency. Nocturia is common as well. The bladder does not empty as efficiently in older people. • Childbirth and gravity tend to weaken the pelvic floor, potentially leading to stress incontinence in older adult women. Pregnancy • During pregnancy, the growing fetus compromises bladder space and compresses the bladder, resulting in urinary frequency. Poor abdominal muscle tone also contributes to frequency. • A 30% to 50% increase in circulatory volume occurs during pregnancy, which increases renal workload and output. • The hormone relaxin, produced during pregnancy, causes relaxation of the bladder sphincter

Intravenous Pyelography

An intravenous pyelogram (IVP) is an x-ray study of the kidneys, the bladder, the ureters, and the urethra. The images show the size, shape, and position of the urinary tract. The procedure for IVP involves the injection of contrast material into a vein. X-ray images are then taken at timed intervals. An IVP commonly is performed to identify kidney stones, tumors, or infection; to measure the size of a tumor of the urinary tract; and to look for urinary tract damage after injury. Contraindications for IVP include pregnancy, severe kidney disease, and an allergy to iodine. The patient should not eat or drink for 8 to 12 hours before the test and may need a laxative or enema to ensure that the bowels are empty. Risks involved with IVP are allergic reactions to the contrast material and sudden kidney failure associated with conditions such as diabetes, kidney disease, sickle cell disease, and pheochromocytoma (a rare adrenal gland tumor), as well as medications that affect the kidney (

Ultrasound Assessment of the Bladder or Kidneys

An ultrasound scan may be performed to assess the size, shape, and location of the kidneys; with use of specialized ultrasound technology, blood flow can be monitored during the procedure. Ultrasound studies may be safely conducted in pregnant women and in patients who have allergies to contrast media, because no radiation or contrast dyes are used. Factors or conditions that interfere with ultrasound results include severe obesity, recent barium studies, and excessive flatus or intestinal gas. Generally, no patient preparation such as fasting or sedation is required. If the bladder is to be studied, the patient will be required to drink fluid and refrain from voiding before the procedure. The ultrasound examination itself causes no pain; however, the patient may complain of discomfort from lying still with a full bladder for the duration of the procedure.

Anuria

Anuria is the failure of the kidneys to excrete urine. Anuria occurs as a result of any process that limits effective blood flow through the kidneys. Diagnosis of anuria is made when a catheter is passed into the bladder and no urine is present. Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure. Acute anuria is life-threatening and requires emergent investigation to determine the cause. As waste accumulates, the patient becomes at risk for coma or death. Depending on the severity of anuria and the alterations in the patient's fluid and electrolyte levels, artificial filtering of waste products using renal dialysis may be necessary.

Discontinuing an Indwelling Catheter

Background • Indwelling catheters are a primary source of urinary tract infections (UTIs) and should be removed as soon as medically possible. • The Centers for Disease Control and Prevention (CDC) has issued guidelines for insertion, use, and removal to aid in decreasing catheter-associated UTIs. • The patient may experience burning and difficulty voiding, as well as frequency or retention, after removal. • Monitor the patient's output closely. • If the patient is urinating only small quantities, assess for bladder distention. • If the patient has not urinated during the 6 to 8 hours after removal of the catheter: • Assess for urinary retention via bladder scan. • Notify the primary care provider (PCP). • Intermittent catheterization with a straight catheter or reinsertion of an indwelling catheter may be necessary. • Postoperative patients should have an indwelling catheter removed within 24 hours of surgery unless there are other appropriate reasons for the catheter to remain in place

Blood Urea Nitrogen and Creatinine

Blood levels of urea and creatinine are used to evaluate renal function. Urea is the end product of protein metabolism and is measured as BUN. Creatinine is a waste product that is produced in the blood as a by-product of muscle metabolism. BUN concentration is a measure of the urea level in the blood. Urea is cleared by the kidney, and levels may be increased in the patient who is dehydrated or who has a disease that compromises the function of the kidney. Normal values for BUN in the blood are 7 to 20 mg/dL. Elevated levels may indicate kidney injury or disease as well as conditions such as diabetes, high blood pressure, blockage of the urinary tract, a high-protein diet, severe burns, gastrointestinal bleeding, or problems such as dehydration or heart failure, which affect blood flow. Medications also may elevate BUN levels. Low BUN values may be caused by a low protein diet, malnutrition, liver damage, or drinking excessive amounts of liquids. No pretest preparation is required; however, medications, such as certain antibiotics, corticosteroids, and diuretics, may affect test results. Creatinine is filtered along with other waste products from the blood by the kidney and eliminated in the urine. It is made at a steady rate, and levels are not affected by diet or by normal physical activities. The patient with kidney damage has decreased urinary creatinine but increased serum levels. The amount of creatinine in the blood is directly related to muscle mass; generally, creatinine levels are higher in men than in women. Normal values of serum creatinine are 0.6 to 1.2 mg/dL for women and 0.8 to 1.4 mg/dL for men. BUN and serum creatinine are viewed in relationship to each other. Sudden rises in BUN-to-creatinine ratios occur in acute kidney failure associated with shock, dehydration, or severe gastrointestinal bleeding. Low BUN-to-creatinine ratios are seen in patients on low-protein diets or those with severe muscle injury, cirrhosis of the liver, or syndrome of inappropriate antidiuretic hormone (SIADH).

Foley and Coude Catheters

Both Foley and coudé catheters are designed to be left in place, draining the bladder continuously or intermittently for an extended period of hours, days, or weeks.

Routine Catheter Care

Catheters should be inserted using aseptic technique and sterile equipment, as recommended by the Centers for Disease Control and Prevention. Once the catheter is placed, the urethral meatus should be cleansed with soap and water once or twice daily. The routine use of povidone-iodine or neomycin-bacitracin solutions, ointments, or creams with the cleansing routine is not recommended and shows no advantage in infection prevention. Catheter bags should be consistently kept below the level of the bladder, to prevent backflow leading to catheter-acquired UTI. Preconnected closed-drainage urinary catheterization systems should be used to reduce risk of interruption of the system by staff or the patient's family. Routine irrigation of the indwelling catheter is not recommended for UTI prevention. Arbitrary and routine intervals for changing catheters are not recommended. Catheters should be changed if debris or encrustation of the catheter is noted. Catheter bags should be emptied when two-thirds full.

Medication

Certain drugs may alter the production, formation, concentration, clarity, and color of urine. Medications that affect the autonomic nervous system may interfere with the urination process, causing urinary retention. Blood pressure medications, specifically diuretics, change the ratio of water and electrolyte reabsorption within the kidneys, which will alter the concentration of urine.

Medication

Certain medications can affect the color of urine. Antimalarial drugs, laxatives, and metronidazole may cause the urine to turn brown or tea-colored. Rifampin, warfarin, and phenazopyridine may turn the urine orange. Blue-green urine can be seen in patients receiving medications such as cimetidine, indomethacin, or promethazine

Laboratory Tests

Common tests to evaluate urinary function include measurement of blood urea nitrogen (BUN) and serum creatinine levels to determine kidney function, urinalysis, urine culture to determine the cause of a UTI, and 24-hour urine collection to measure creatinine clearance.

Computed Tomography

Computed tomography (CT) of the kidneys, ureters, and bladder is used to diagnose kidney stones, bladder stones, or blockage of the urinary tract. Contrast media may be used during the procedure to help identify blockages, growths, infections, or other diseases. The patient may be required to have nothing by mouth for 8 to 12 hours before the test and may be prescribed a laxative or enema. A sedative may be given to help the patient relax before the procedure. The scan usually takes 30 to 60 minutes but may take up to 2 hours, during which time the patient must lie still. After the procedure, the patient should be encouraged to drink liquids to flush out any contrast material that was given.

Condom Catheters

Condom catheter use is less likely to lead to bacteriuria, UTI, and death than use of indwelling catheters in patients who retain urine. Use of condom catheters, however, is not without risk: Skin necrosis, penile strangulation, urethrocutaneous fistulas, dermatitis, skin erosion, pain, and localized infection have been reported. Male patients report that condom catheters are more comfortable and less painful than indwelling urethral catheters. Hand hygiene should be performed before and after catheter care. A new condom catheter should be placed daily, along with assessment for potential complications. Perform perineal care while the condom catheter is off. Use a clean washcloth with soap and water, and pull back the foreskin if the patient is uncircumcised. Rinse and dry the penis, and pull the foreskin down over the head of the uncircumcised penis to prevent swelling before placing a new catheter.

Cystoscopy

Cystoscopy is examination of the bladder and urethra through a cystoscope, which is inserted into the urethra and advanced into the bladder. The procedure permits visualization of areas that do not show up well on x-ray images. Cystoscopy is performed to determine the cause of hematuria, dysuria, incontinence, frequency, urgency, or retention. Cystoscopy is used additionally in the diagnosis of conditions that cause blockage of the urethra, as well as for treatment of urinary tract problems. Biopsy of tissues and removal of small stones or growths also can be performed using cystoscopy.

Blockages and trauma to the urethra

Despite its multiple applications, in addition to being the primary cause of UTIs, urinary catheterization may lead to blockages and trauma to the urethra.

Pathologic Conditions

Diseases of the kidneys may reduce the production of urine. Heart and circulatory disorders can lead to diminished blood flow to the kidneys, affecting urine production. Calculi may obstruct the ureter, blocking the flow of urine. Dehydration causes water retention, resulting in decreased urinary output. Some pathologic conditions can result in bladder removal. In such instances, urine will need to be diverted from the urinary tract to exit the body.

Hemodialysis

During hemodialysis , the patient's blood flows continually from the body through vascular catheters to the dialysis machine. It then goes through the machine's filters, and ultrafiltrate (a liquid from which the blood cells and the blood proteins have been filtered out) is created. The frequency of hemodialysis is dependent on patient status. Once patients with chronic renal failure begin hemodialysis, they typically are required to undergo treatments three times per week or more often.

Urine formation is a result of 3 processes

Filtration initially occurs in the glomerulus as fluid moves across a membrane as the result of a pressure difference. Reabsorption occurs in the renal tubule as most of the filtrate moves back into the blood. At this point waste products, excess solutes, and small amounts of water are not reabsorbed but are secreted. As secretion takes place, urine is produced. Urea, water, and other waste substances form urine as they pass through the nephrons down the renal tubules

Monitoring Intake and Output

For a majority of hospitalized patients, not just those with urinary concerns, it is necessary to monitor and record patient intake and output. Recording of fluid intake and output can be delegated to a qualified UAP, if the nurse takes ultimate responsibility to make sure the intervention is completed satisfactorily. While evaluating intake and output, the nurse should always take into consideration whether the patient has recently undergone surgery, is receiving medications that influence fluid intake and output, or has a medical condition such as kidney or heart failure that affects fluid balance. Intake includes all food and oral fluids as well as tube feedings and intravenous fluids. In most facilities, solid food intake is documented as an estimated percentage of a meal consumed (e.g., 85% of lunch). Oral fluids are recorded in milliliter (mL) amounts for the size of the container from which they are consumed.

Microscopic Analysis

For microscopic analysis, urine is spun in a centrifuge and sediment settles at the bottom. The sediment is then spread on a slide and checked for red or white blood cells, casts, plugs, or crystals. The presence of crystals in the urine may indicate that stones are present. Bacteria, yeast, and parasites are not normally present in urine and, when present, usually indicate infection.

Bladder and Urethra

From the ureters the urine flows slowly into the bladder, located below the umbilicus and above the symphysis pubis in the lower abdomen, for storage. The bladder walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. Sphincter muscles at the base of the bladder help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. The urethra transports urine from the bladder to outside the body for elimination and bladder emptying. The innervation of the bladder signals when it is time to urinate and empty the bladder. This impulse is referred to as urge or urgency . The brain signals the bladder muscles to tighten and the sphincter muscles to relax, which squeezes urine out of the bladder through the urethra. When all of the signals occur in the correct order, normal micturition , or urination, occurs.

Hematuria

Hematuria is the abnormal presence of red blood cells in the urine. The bleeding can originate at any point along the urinary tract. Both gross, or visible, and microscopic hematuria may represent serious underlying disease. The color of the urine does not reflect the degree of blood loss. Causes of hematuria include irritation or inflammation of the mucosa and invasion by bacteria. Malignancy, renal stones, trauma, infection, medications, tumors of the kidney, renal cysts, infarction, and arteriovenous malformations (AVM, abnormal connections between arteries and veins) may contribute to hematuria.

Suspected Urinary Tract Infection

If a UTI is suspected, urine may be checked for nitrates. Nitrate levels increase when bacteria are present. A leukocyte esterase test determines the level of white blood cells in the urine; elevated levels indicate presence of a UTI.

Developmental Factors

Individual control of urination changes with age. The infant has no urinary control, and the young child will not gain control until between the ages of 2 and 5 years. Preschoolers may have acquired the ability of independent toileting; however, accidents may occur, and enuresis may be an issue until the age of approximately 5 years. By school age, the child's elimination patterns should be well established. Nocturnal enuresis (bedwetting) is commonly seen in children until full bladder control is established and should not be considered a problem until after age 6 years. Elderly people are at risk for elimination problems secondary to age-related decreased function of the kidneys. Urgency and frequency often are reported as the muscles supporting the bladder weaken. Retention of urine may lead to nocturia. Prostate enlargement that causes narrowing of the urethra may impair the ability of male patients to completely empty the bladder. Residual urine may predispose the elderly patient to bladder infections.

Kegel exercises

Kegel exercises are recognized to help keep the female pelvic floor toned, which reduces the risk of incontinence. When Kegel exercises are performed regularly, improvement normally is seen in approximately 8 to 10 weeks.

Conflicts in voiding routines

Many people follow routines to promote voiding, but in the health care facility, conflicts with a person's normal routine are common. For example, bed rest, medication use, prescribed medical therapies, and privacy issues can alter the patient's pattern. Proper integration of the patient's habits into daily care will aid in preventing problems with elimination.

Muscle Tone

Muscle tone plays a direct role in filling and emptying of the bladder. Poor muscle tone affects the ability of the bladder to contract and expand completely. Changes in the muscle tone of the pelvic floor can alter sphincter control, causing urine leakage.

Nocturia

Nocturia is excessive urination at night. The affected person may awaken several times during the night to urinate, which can disrupt the sleep cycle. Normally, urine decreases in amount and becomes more concentrated at night. Most people can sleep 6 to 8 hours without having to urinate. Nocturia commonly is seen in men with benign prostatic hyperplasia (BPH) and in postmenopausal women as a consequence of decreased bladder tone. It also may be associated with the use of medications such as diuretics, as well as with UTIs, congestive heart failure, cystitis (inflammation of the bladder), and diabetes. Drinking too much fluid before bedtime and sleep disorders also may have an effect. The patient with nocturia should be encouraged to maintain a diary of fluid intake, frequency of urination, urine output, and daily weights, taken at the same time on the same scale, to help determine an appropriate treatment regimen.

Glucose

Normal urine contains very little to no glucose. The urine glucose concentration is used to screen for diabetes and to assess glucose tolerance. Glucose in the urine may be a sign of kidney damage or disease. Urine glucose levels are not an adequate measure of blood glucose levels. In the uncontrolled diabetic patient, glucose may appear in the urine.

Odor

Normal urine usually does not smell very strong. Dehydration may increase the odor of urine as more waste is excreted in smaller volume. Foods (most notably, asparagus) and some diseases are associated with a change in the odor of urine. In uncontrolled diabetes, the urine can have a sweet fruity odor, whereas in infections, a strong, unpleasant odor may be evident.

Urine for Protein

Normally, urine does not contain protein. Protein modules generally are too large to escape from the glomerulus capillaries into filtrate. Protein in the urine may be associated with fever, vigorous exercise, pregnancy, and some diseases, such as kidney disease. In conditions such as glomerulonephritis (inflammation of the glomeruli of the kidney), the cell membrane can become permeable and allow proteins to cross.

Normal Structure and Function of the Urinary System

Nutrients from food are used by the body to maintain all of its functions. The kidneys excrete and reabsorb water and electrolytes from the body. The urinary system controls the composition of blood by removing waste products such as urea and conserving useful substances. Urea is produced when protein-rich foods are digested. The urinary system helps to control blood pressure and plays a crucial role in acid-base balance.

Oliguria

Oliguria is defined as reduced urine volume less than 1 mL/kg/h in an infant, less than 0.5 mL/kg/h in children, and less than 400 mL/day in adults. Oliguria is a symptom of acute or chronic renal failure, which can be classified as prerenal, renal, or postrenal failure. Signs and symptoms of oliguria vary according to the underlying cause. The patient may be breathless, with pale, clammy, and cool skin, and have a low blood pressure; there may be signs of edema or anemia; and changes in the heart rhythm, hepatomegaly, and hypertension may be present The management of oliguria includes treatment for any reversible causes. If the intravascular volume is low, fluids should be administered for restoration. Fluid balance should be monitored and maintained with electrolyte monitoring and correction. Input and output should be recorded, along with daily weights. Potassium retention is common in renal failure. Potassium levels need to be monitored, and dialysis should start when serum potassium exceeds 6.5 mEq/L. Potassium intake should be limited until urine flow is reestablished. Dialysis may be required until the kidneys recover. The overall goal of dialysis is to remove toxins and to maintain fluid, electrolyte, and acid-base balance

Intake and Output positive or negative balance

Once intake and output are recorded, the balance is calculated and documented for assessment. This allows all members of the health care team to determine if a patient has a positive or negative intake-output balance. If the patient has consumed more fluid than has been excreted, the balance is positive. When the patient excretes or loses more fluid than what is consumed, the balance is considered negative

Output

Output is measured by collecting fluid and drainage from bedpans, urinals, urinary catheters, drains, ostomy bags, nasogastric tubes, or collection devices commonly referred to as urine "hats" placed in the front of a toilet or bedside commode. All liquid secretions are measured in mL using a disposable, graduated container, which is washed after each use. Each time output receptacles are emptied, the volume is carefully documented. Liquids that are measured and recorded as output include urine, liquid feces, vomitus, blood, and nasogastric and drainage excretions (including those from chest tubes).

Dysuria

Painful urination, known as dysuria, may result from a number of factors, including bladder or UTI, cystitis, sexually transmitted disease, yeast infection, kidney or bladder stones, prostatic enlargement, malignancy, and allergic or irritant reaction to soaps, vaginal lubricants, spermicides, contraceptive foams and sponges, tampons, and toilet paper. Patients with dysuria often complain of burning that follows urination. Often a delay in initiating voiding or hesitancy is associated with dysuria

Pathologic Conditions

Patients with hypercalcemia may have blue-green urine. Those with liver failure from hepatitis and cirrhosis may have brown to tea-colored urine. Severe dehydration can cause urine to range anywhere between dark yellow-orange and tea color.

Polyuria

Polyuria Polyuria is an excessive volume of urine formed and excreted each day. For an adult, this would be 2500 mL or more of urine per day. Polyuria may be caused by consumption of a large amount of fluids, especially fluids that contain caffeine or alcohol, which have a natural diuretic effect; ingestion of too much salt or glucose; use of diuretic medications; diabetes; imaging tests that involve contrast media or dye; or other disease processes.

Postrenal failure

Postrenal failure is related to a mechanical or functional obstruction of the flow of urine. Oliguria is most easily observed by the nurse through frequent monitoring of the patient's urinary output.

Prerenal Failure

Prerenal failure occurs as a result of reduction in blood flow to the kidneys. Causes of prerenal failure include dehydration, vascular collapse, and low cardiac output.

Urinary Catheterization: Insertion and Care

Purpose: Urinary catheters are used to: • Accurately monitor urinary output • Assess bladder function • Obtain urine specimens • Relieve bladder distention and discomfort • Allow for healing after surgical procedures • Irrigate the bladder • Instill medications into the bladder • Manage urinary incontinence • Manage urinary retention

Normal urine color

Ranges from pale yellow to amber. Common causes of urine discoloration are medications, vitamins (such as vitamin B), foods (such as asparagus or elderberries), and food dyes. Urine color may be altered by certain health problems. Concentrated urine is darker in color (deep amber) and may be the result of dehydration, low fluid intake, or reduced urine production. Dilute urine ranges in color from clear to pale straw and may be a consequence of excessive fluid intake or the inability of the kidneys to concentrate urine. Red or pink urine may be associated with bleeding, strenuous exercise, UTI, enlarged prostate, kidney or bladder stones, kidney disease, or cancer.

Renal Failure

Renal failure is seen in patients with actual kidney damage. Structural issues with the kidneys, from primary glomerular diseases or vascular lesions, result in renal failure.

Perineal Care

Skin care is important in patients with urinary elimination issues, including those with indwelling catheters, to help prevent infection. Urine is very irritating to the skin. When urine accumulates on the skin, it is converted to ammonia, which causes the skin to remain moist and possibly become macerated (softened and broken down). The patient is at risk for skin breakdown, ulceration, and infection. Frequent perineal care is necessary, although use of harsh soaps, bubble baths, powder, or sprays, which can irritate the urethra, leading to inflammation and infection, should be avoided. The perineal area should be cleansed frequently with soap and water or no-rinse cleansers and dried thoroughly. In female patients, cleansing is done from front to back, especially after defecation. Skin should be check regularly for redness or signs of breakdown. Skin protectants, such as Baza Protect Moisture Barrier Cream, may be used to help prevent breakdown or heal affected areas. Specialty incontinence pads that draw moisture away from the surface of the skin may be used for the incontinent patient.

Surgical and Diagnostic Procedures

Surgical and diagnostic procedures may alter the formation, concentration, color, and passage of urine. Ability to pass urine is affected by swelling. Postoperative bleeding can transform the color and quantity of the urine. Anesthesia contributes to urine retention by decreasing awareness of the need to void.

Suprapubic catheter

Surgical placement of a suprapubic catheter may be undertaken if urethral catheterization is either contraindicated or unsuccessful. Men and women with urethral obstructions or injuries and men with prostate cancer and BPH are most often candidates for this type of catheter. Suprapubic catheters are placed with use of local or general anesthesia through the abdominal wall approximately 4 to 5 cm above the symphysis pubis and secured with sutures. Urine drains through the suprapubic catheter into an attached bag secured to the patient's leg or abdomen. Patients with suprapubic catheters are encouraged to drink plenty of fluid, to maintain hydration and to promote urinary excretion. Care should include daily cleansing around the catheter site with soap and water. Patients should be instructed to avoid the use of creams or lotions around the site. The nurse should assess for any seepage around the site and for signs of infection such as redness or discharge. Documentation should include site appearance; the color, volume, and characteristics of excreted urine; and patient tolerance of the catheter if it is newly placed.

Inspection and Auscultation

The abdomen is inspected for skin color, contour, symmetry, and distention while the patient is in a supine position. Normally, the abdomen is not distended and is symmetric and free of bruises, masses, and swelling. A distended bladder may be visible in the suprapubic area. A bladder scan can be conducted by the nurse with handheld ultrasound equipment to quickly determine the extent of urinary retention. Abdominal distention may be seen in conditions such as polycystic kidney disease, pyelonephritis, ascites, and pregnancy. In addition, auscultation of the left and right renal arteries is performed to assess circulation sounds. Normally, no sounds are heard.

pH

The acid-base balance in the body is determined by pH, which reflects the acidity or alkalinity of the urine. Urine normally is slightly acidic, with an average pH of 6. Urine with a pH of 4 is very acidic. A pH of 7 is neutral, and a pH of 9 is very alkaline. The pH is useful in determining the kidneys' response to acid-base imbalances. In metabolic acidosis, the urine pH decreases as the kidneys excrete hydrogen ions; in metabolic alkalosis, pH of the urine increases. Maintaining a healthy pH helps prevent formation of kidney stones.

Amount

The amount of urine that a patient eliminates can vary, depending on factors such as fluid intake, dehydration, and retention. The normal urinary output is approximately equal to fluid intake. Adult urinary output of approximately 60 mL/hour is considered normal.

Kidneys

The kidneys are the major excretory organs of the body. The two kidneys are located bilaterally below the ribs toward the middle of the back. They filter liquid waste from the blood, balance electrolytes in the blood, regulate blood volume and pressure, produce erythropoietin for red blood cell formation, synthesize vitamin D to help control calcium levels, and maintain the acid-base balance of the extracellular fluid

Obtaining Urine Specimens

The nurse is responsible for collecting urine specimens. Specimens may be collected for routine urinalysis by having the patient void into a specimen cup or into a clean urinal or bedpan. For culture and sensitivity testing, urine is collected by the clean-catch, or midstream, method, using a sterile specimen cup. Specimens also can be obtained by performing straight catheterization using sterile technique or by removal of a specimen from the tubing of an indwelling catheter or urinary diversion collection bag. Care needs to be taken to ensure that the specimen is not contaminated.

Nursing interventions in urinary continence

The nurse must focus on activities that will help the patient with compromised urinary elimination return to the normal state of function or adapt to changes in the state of function. Nursing interventions to help patients achieve urinary continence and complete emptying of the bladder and independent toileting include promoting adequate fluid intake, teaching self-care activities, and assisting with voiding. Collaborative interventions require the assistance of the PCP or other professionals, such as a physical therapist or nutritionist.

Ketones

The presence of ketones in the urine (ketonuria) indicates that fat has broken down for energy. Ketones are normally not passed in the urine. Large amounts of ketones in the urine may indicate diabetic ketoacidosis. A diet low in sugars and carbohydrates, prolonged fasting or starvation, and vomiting also may be associated with ketonuria.

Specific Gravity

Urinalysis for specific gravity monitors the balance of water and solutes (solid matter) in urine. Normal specific gravity in an adult is 1.005 to 1.030. The higher the level of specific gravity, the more solid material is contained in the urine. Fluid intake has a direct relationship to specific gravity. If large volumes of water are consumed, dilute urine is produced, which has a low specific gravity. Specific gravity is high in conditions of dehydration.

Urinalysis

Urinalysis is an assessment of the urine at a single point in time. Urinalysis is a screening tool for UTI, kidney disease, and other conditions. Single samples can be used for detection or measurement of bacteria, glucose, white blood cells, red blood cells, proteins, and other substances. Urinalysis samples are collected by having the patient void in a specimen cup, or samples may be taken using catheterization. Only 1084small samples of urine (10 to 15 mL) are required for urinalysis testing.

Urinary Catheterization

Urinary catheterization most often is performed by introducing a catheter into the patient's urethra to reach the bladder. For urethral catheterization, any of four different kinds of catheters—straight, Foley, triple-lumen, and coudé—may be used. Straight catheters are single-lumen devices, designed for one-time or short-term catheterization: The catheter is left in place only long enough to drain the patient's bladder.

Types of Urinary Incontinence

Urinary incontinence can be divided into several types. Stress incontinence is loss of urine control during activities that increase intraabdominal pressure, such as coughing, sneezing, laughing, or exercise. Urge incontinence involves a sudden strong urge to void, followed by rapid bladder contraction. The affected person does not have enough time for toileting between recognition of the urge to urinate and the onset of voiding. Mixed incontinence is a combination of both stress and urge incontinence. Functional incontinence refers to lack of urine control in the absence of any abnormalities of the urinary tract; it occurs when some physical limitation in functioning, such as difficulty with clothing fasteners or impaired mobility, hinders reaching the toilet before voiding occurs. Overflow incontinence is seen in patients who are unable to empty the bladder completely, resulting in a constant dribbling of urine or increased frequency of urination. Overflow incontinence results from weakened muscles of the bladder, which may be a consequence of certain pathologic conditions. Temporary incontinence can occur in association with factors such as severe constipation, infections in the urinary tract or vagina, or medication usage.

Urinary Incontinence

Urinary incontinence is the inability to control the passage of urine.

Urinary Retention

Urinary retention is the inability of the bladder to empty. It is caused by an obstruction in the urinary tract or by a neurological disorder. The patient with chronic urinary retention has difficulty starting a stream of urine or emptying the bladder. Once started, the urine flow is weak. Chronic urinary retention causes mild but constant discomfort. During episodes of acute urinary retention, the patient is unable to urinate despite a full bladder. In another presentation, the patient may express the need to urinate frequently and when finished still feel urge. Dribbling may occur between trips to bathroom because the bladder is constantly full. Acute urinary retention is a medical emergency necessitating prompt medical intervention.

UTI

Urinary tract infections (UTIs) are the result of bacteria in the urine. Infection occurs when bacteria from the digestive tract, usually Escherichia coli, invade the urethra and multiply. UTI is the single most common hospital-acquired infection. People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and elderly people with bladder control loss. Diabetes or other diseases that suppress the immune system increase the risk of UTI.

Normal Urine Characteristics

Urine can be produced in small or large amounts. It can be dilute or very concentrated. Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi. The average adult passes one to two quarts (960 to 1920 mL) of urine per day, depending on the amount of fluids consumed, medications, medical conditions, and dietary intake (such as salt). During the night, urine formation decreases to approximately half of what is produced in the daytime.

Culture and Sensitivity Testing

Urine culture and sensitivity testing are performed for diagnosis of a UTI. Urine in the bladder normally is sterile; it does not contain bacteria or organisms. If organisms grow in the culture, sensitivity testing is performed to determine the appropriate antibiotic for treatment.

Nephrons

Urine is formed by tiny filtering units called nephrons , which are the functional units of the kidney.

Clarity

Urine normally is clear. Cloudy urine may indicate the presence of bacteria, blood, sperm, crystals, or mucus. After bladder or kidney surgery, patients may excrete bloody urine containing clots. These patients typically require irrigation of the bladder using a three-way catheter to prevent potential blockage.

Palpation and Percussion

Using a bimanual technique, the PCP will attempt to palpate the kidneys, which rarely are palpable unless they are enlarged from tumors, cysts, or hydronephrosis. Palpation of an enlarged kidney may be painful for the patient. Assessment by a PCP may include blunt or indirect percussion to further assess the kidneys. The patient should feel no pain or tenderness with pressure or percussion. Pain or discomfort during or after percussion is suggestive of kidney disease. Percussion of the bladder determines location and degree of fullness.

During the initial assessment,

directed at gathering basic subjective and objective data, the patient's physical and mental abilities must be considered, prioritization of immediate problems identified, and relief of symptoms must be addressed before a full evaluation is undertaken. Signs of distress and the patient's orientation to his or her circumstances should be noted. Changes in mental status may be a symptom of elevated nitrogenous wastes in the blood secondary to kidney dysfunction. Frequent urination and burning during micturition are classic symptoms of UTI. Fatigue is a frequent complaint of patients with kidney disorders. After completion of a focused interview, including past and present health history, the nurse needs to conduct a physical inspection of the abdomen. Inspection of the urine also is done to evaluate the patient's hydration status and to identify changes related to the use and effects of medications and illnesses. A discussion with the patient focusing on urinary elimination patterns and abnormalities may be difficult, because elimination often is regarded as a private matter; however, it must be done.

To maintain asepsis

hospitalized patients are provided with a bedpan, urinal, or both for personal use that is marked with their name or room number. The bedpan typically is stored in the bathroom. A urinal should be stored out of sight but within reach. It should be kept separate from other equipment used for hygienic care, and aseptic practices prohibit its being kept on the floor, under the bed, or on the over-bed table. Bedpans and urinals should be rinsed thoroughly after each use.

Causes of acute urinary incontinence

include extended bed rest, medications, increased amount of urine, mental confusion, pregnancy, prostate infection or inflammation, stool impaction, and urinary tract infections. Chronic urinary incontinence issues may be related to bladder cancer, bladder spasms, depression, enlarged prostate, neurologic conditions, pelvic prolapse in woman, pelvic floor muscle damage that may occur with a hysterectomy, spinal injuries, or weakness of the bladder sphincter.

A urinary diversion

is a surgical procedure performed when bladder function is impaired owing to trauma or disease involving the bladder, the distal ureters, or, rarely, the urethra. The diversion may be temporary or permanent and can be classified as continent or incontinent.

Dialysis

is a technique by which fluids and molecules pass through an artificial semipermeable membrane and are filtered by means of osmosis.

Peritoneal dialysis

is performed by instilling dialysis solution into the patient's abdominal cavity through an external catheter. After the solution rests within the peritoneal cavity for a prescribed period of time, it is removed from the body through the catheter. In peritoneal dialysis, the abdominal cavity functions as the dialyzing membrane through which fluid and molecules are exchanged and toxic substances are removed from the body.

The cause of enuresis

the involuntary passing of urine, may be structural or pathologic, although it may be related to non-urinary problems such as constipation, stress, and illness.

Evidence-Based Practice

• "Unless obstruction is anticipated (e.g., as might occur with bleeding after prostate or bladder surgery), bladder irrigation is not recommended. Routine irrigation of the bladder with antimicrobials is not recommended"

Collaboration and Delegation

• Bladder irrigation may not be delegated to unlicensed assistive personnel (UAP) without a nurse's assistance.

Collaboration and Delegation Catheter

• Inserting a straight catheter may be delegated to unlicensed assistive personnel (UAP) without a nurse's assistance following assessment of the patient, depending on the state and the institution's policies and procedures and provided that the UAP has received the appropriate specialized training.

Team Approach to Meeting Patient Elimination Needs

• Unlicensed assistive personnel (UAP) often aid patients in toileting. The nurse must communicate necessary actions, such as measuring the amount of urine, noting its color, and determining the frequency of urination. The nurse must stress to the UAP the necessity of documenting voiding patterns. • In some settings, UAP may be permitted to insert a urinary catheter, but it is not routine practice. The UAP may assist with positioning the patient, focusing lighting, maintaining patient position, and providing comfort measures.