Timby chapter 30 Touhy chapter 16 urinary elimination
Gerontologic Considerations
An individualized toileting schedule should be maintained, for example, at intervals of must be offered every 90 to 120 minutes for clients who have difficulty maintaining continence. Absorbent products may interfere with the person's independence in toileting and may lead to skin breakdown. Incontinence products are never used primarily for staff convenience in institutional settings. In addition, an older person should never be reprimanded for an episode of incontinence. When efforts to restore continence are unsuccessful, nurses can encourage older adults to verbalize their feelings and identify interventions helpful in maintaining dignity, ultimately enabling older adults to participate in meaningful activities.
external catheter
An external catheter, also known as a condom catheter, (a urine-collecting device applied to the skin) is not inserted within the bladder; instead, it surrounds the penis (Fig. 30-6). An external catheter is obviously more effective for male clients.
open system
An open system is one in which the retention catheter is separated from the drainage tubing to insert the tip of an irrigating syringe. Opening the system creates the potential for infection because it provides an opportunity for pathogens to enter the exposed connection. Consequently, it is the least desirable of the three methods.
catheterization
Catheterization (the act of applying or inserting a hollow tube), in this case, refers to using a device inside the bladder, or externally about the urinary meatus. A urinary catheter is used for various reasons: Keeping incontinent clients dry (catheterization is a last resort that is used only when all other continence measures have been exhausted) Relieving bladder distention when clients cannot void Assessing fluid balance accurately Keeping the bladder from becoming distended during procedures such as surgery Measuring the residual urine Obtaining sterile urine specimens Instilling medication within the bladder Types of Catheters
Nursing implications
Clients with urinary elimination problems may have one or more of the following nursing diagnoses: Toileting Self-Care Deficit Impaired Urinary Elimination Urinary Retention Risk for Infection Stress Urinary Incontinence Urge Urinary Incontinence Reflex Urinary Incontinence Functional Urinary Incontinence Situational Low Self-Esteem Risk for Impaired Skin Integrity
functional
Control over urination lost because of inaccessibility of a toilet or a compromised ability to use one ex. Voiding occurs while attempting to overcome barriers such as doorways, transferring from a wheelchair, manipulating clothing, acquiring assistance, or making needs known. cause: Impaired mobility, impaired cognition, physical restraints, inability to communicate nursing approach: Clothing modification Access to a toilet, commode, or urinal Assistance to a toilet according to a preplanned schedule
abnormal characteristics of urine
Hematuria: urine containing blood Pyuria: urine containing pus Proteinuria: urine containing plasma proteins Albuminuria: urine containing albumin, a plasma protein Glycosuria: urine containing glucose Ketonuria: urine containing ketones
factors affecting urinary elimination
Patterns of urinary elimination depend on physiologic, emotional, and social factors. -the degree of neuromuscular development and the integrity of the spinal cord -the volume of fluid intake and the amount of fluid losses, including those from other sources -the amount and type of food consumed -the person's circadian rhythm, habits, opportunities for urination, and anxiety.
intervention: Instruct the client to restrain urination as long as possible after the warning sign is perceived.
Rationale: Efforts to delay urination help to reverse an established habit of overresponding to an urgent need to void.
intervention: Suggest that the client uses a technique such as breathing deeply, singing a song, or talking about family to delay voiding.
Rationale: Focusing thoughts on something other than urination may provide sufficient distraction to extend the interval between the warning sign and actual voiding.
intervention: Share the client's progress with the physician.
Rationale: Medical interventions such as prescribing a medication that blocks acetylcholine (anticholinergic agent) may help to inhibit bladder muscle contractions and promote contraction of the urinary sphincter.
intervention: Continue to extend the intervals between voiding until the client is voiding no more frequently than q4h in a 24-hour period.
Rationale: Reconditioning the control of urination is facilitated by repetition and gradually extending the efforts to control voiding.
reflex
Spontaneous loss of urine when the bladder is stretched with urine, but without prior perception of a need to void ex. The person automatically releases urine and cannot control it. cause: Damage to motor and sensory tracts in the lower spinal cord secondary to trauma, a tumor, or other neurologic conditions nursing approach: Cutaneous triggering Straight intermittent catheterization
stress
The loss of small amounts of urine when intra-abdominal pressure rises ex. Dribbling is associated with sneezing, coughing, lifting, laughing, or rising from a bed or chair. cause: Loss of perineal and sphincter muscle tone secondary to childbirth, menopausal atrophy, prolapsed uterus, or obesity. nursing approach: Pelvic floor muscle strengthening, Weight reduction
assisting clients with urinary elimination
commode,urinal, bedpan
urinary system
consists of the kidneys, ureters, bladder, and urethra. These major components, along with some accessory structures, such as the ring-shaped muscles called the internal and external sphincters, work together to produce urine (fluid within the bladder), collect it, and excrete it from the body.
intervention: Ensure an oral fluid intake of at least 1,500-2,000 mL/day.
rationale: An adequate fluid intake reduces the potential for urinary infection or renal stone formation.
intervention: Encourage the client to eliminate the intake of beverages that contain caffeine or alcohol.
rationale: Caffeine promotes urination; alcohol inhibits the antidiuretic hormone, which prevents the reabsorption of water in the nephrons and leads to an increased formation of urine.
Invervention: Keep a record of the frequency of voidings and the length of time between the warning sign for voiding and actual voiding for 3 days beginning 8/1 through 8/3.
rationale: Documenting the client's unique pattern of urination facilitates appropriate nursing interventions.
intervention: Assist the client to the toilet for the purpose of urination at a frequency that corresponds with the client's preconditioning pattern of urination (ie, approximately q1 1/2h), and extend the time by 15 minutes until there is an interval of 2 hours between voidings.
rationale: Increasing the length of time between voidings reduces chronic low-volume voiding, improves bladder muscle tone, and increases bladder capacity, which potentiates achieving continence.
intervention: Praise the client every time a short-term goal of delaying or controlling urination is achieved.
rationale: Positive reinforcement helps to motivate the client to continue efforts to control incontinence.
intervention: Alert all nursing team members to respond as soon as possible to the client's signal for assistance.
rationale: Responding promptly reduces episodes of incontinence and demonstrates a united effort to help the client achieve control of urination.
urinary elimination
the process of releasing excess fluid and metabolic wastes), or urination, occurs when urine is excreted. The need to urinate becomes apparent when the bladder distends with approximately 150 to 300 mL of urine. The distention with urine causes increased fluid pressure, stimulating stretch receptors in the bladder wall and creating a desire to empty it of urine.
Continence training
to restore the control of urination involves teaching the client to refrain from urinating until an appropriate time and place. Continence training primarily benefits clients with the cognitive ability and desire to participate in a rehabilitation program. This includes clients with lower body paralysis who wish to facilitate urination without the use of urinary drainage devices such as catheters. Clients who are not candidates for continence training require alternative methods such as absorbent undergarments.
oliguria
urine output less than 400 mL/24 hours, indicates the inadequate elimination of urine. Sometimes oliguria is a sign that the bladder is being only partially emptied during voidings. Residual urine, or more than 50 mL of urine that remains in the bladder after voiding, can support the growth of microorganisms, leading to infection. Also, when there is urinary stasis (a lack of movement), dissolved substances such as calcium can precipitate, leading to urinary calculi (stones).
age related elimination changes
•Kidney size/function decreases •Decreased renal blood flow •More glucose in urine •Decreased ability to concentrate urine; more dilute, higher risk of F/E problems •Bladder capacity size decreases •Less bladder tone •Weaker contractions during voiding •Enlarged prostate size in men •Decreased estrogen in women
promotion of urination
General measures to promote urination include providing privacy, assuming a natural position for urination (sitting for women, standing for men), maintaining an adequate fluid intake, and using stimuli such as running water from a tap to initiate voiding.
urine specimen collection
Health-care providers collect urine specimens, or samples of urine, to identify microscopic or chemical constituents.
steps
-compile a log of the client's urinary elimination patterns. -Set realistic, specific, short-term goals with the client. -Discourage strict limitation of liquid intake. -Plan a trial schedule for voiding that correlates with the times when the client is usually incontinent or experiences bladder distention. -Communicate the plan to nursing personnel, the client, and the family. -assist the client to a toilet or commode; position the client on a bedpan or place a urinal just before the scheduled time for trial voiding. -Simulate the sound of urination such as by running water from the faucet. -Suggest performing Credé maneuver (the act of bending forward and applying hand pressure over the bladder -Instruct paralyzed clients to identify any sensation that precedes voiding such as a chill, muscular spasm, restlessness, or spontaneous penile erection -Teach clients with stress incontinence to perform pelvic floor muscle exercises (Kegel exercises) which are isometric exercises to improve the ability to retain urine within the bladder -Assist clients with urge incontinence to walk slowly and concentrate on holding their urine when nearing the toilet.
volume
500-3,000 mL/day
a closed drainage system
A closed drainage system (a device used to collect urine from a catheter) consists of a calibrated bag, which can be opened at the bottom; tubing of sufficient length to accommodate for turning and positioning clients; and a hanger from which to suspend the bag from the bed (Fig. 30-9). The nurse coils excess tubing on the bed but keeps the section from the bed to the collection bag vertical. Dependent loops in the tubing interfere with gravity flow. The nurse also takes care to avoid compressing the tubing, which can obstruct drainage. Placing the tubing over the client's thigh is acceptable.
closed system
A closed system is irrigated without separating the catheter from the drainage tubing. To do so, the catheter or drainage tubing must have a self-sealing port. After cleansing the port with an alcohol swab, the nurse pierces the port with an 18- or 19-gauge, 1.5 in. needle (see Chap. 34). He or she attaches the needle to a 30- to 60-mL syringe containing a sterile irrigation solution. The nurse pinches or clamps the tubing beneath the port and instills the solution, then releases the tubing for drainage. The nurse records the volume of irrigant as fluid intake or subtracts it from the urine output to maintain an accurate intake and output record.
continuous irrigation
A continuous irrigation (the ongoing instillation of solution) instills irrigation solution into a catheter by gravity over a period of days Continuous irrigations keep a catheter patent after prostate or other urologic surgery in which blood clots and tissue debris collect within the bladder and catheter. A three-way catheter is necessary to provide a continuous irrigation. The catheter has three lumens or channels within the catheter, each leading to a separate port. One port connects the catheter to the drainage system; another provides a means for inflating the balloon in the catheter; and the third instills the irrigation solution The steps involved in providing a continuous irrigation are as follows: Hang the sterile irrigating solution from an intravenous pole. Purge the air from the tubing. Connect the tubing to the catheter port for irrigation Regulate the rate of instillation according to the medical order. Monitor the appearance of the urine and volume of urinary drainage.
retention catheter
A retention catheter, also called an indwelling catheter, is left in place for a period of time (see Fig. 30-8). The most common type is a Foley catheter. Unlike straight catheters, retention catheters are secured with a balloon that is inflated once the distal tip is within the bladder. Both straight and retention catheters are available in various diameters, sized according to the French (F) scale (see Chap. 29). For adults, sizes 14, 16, and 18 F are commonly used.
straight catheter
A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen
catheter specimens
For clients who are already catheterized, the nurse clamps the drainage tube for 30 minutes and then aspirates a sample through the lumen of a latex catheter or from a self-sealing port that has been cleansed with an alcohol pad.
Promoting a healthy bladder
Drink 8 to 10 glasses of water before 8 PM Illuminate or reduce the use of coffee tea brown color and alcohol particularly before bedtime Empty bladder completely before and after meals and at bedtime Urinate whenever the urge arises Limit the use of sleeping pills sedatives and alcohol because they decreased sensation to urinate Make sure the toilet is nearby with a clear path to it and good lighting especially at night Maintain ideal body weight Get regular physical exercise Avoid smoking Seek professional treatment for complaints of burning urgency pain blood in urine or difficulty maintaining continents
inserting catheter gerontological considerations
Enlargement of the prostate, a common problem among older men, can obstruct urinary outflow and make catheterization difficult or impossible. Insertion of a urinary catheter should never be forced. Sometimes a malecot catheter is inserted into the bladder through the abdominal wall (suprapubic catheterization) when it cannot be inserted into a narrowed urethra. Indwelling catheters should be avoided if at all possible because older people have increased susceptibility to urinary tract infections. Bladder training or other interventions are much more desirable. If indwelling catheters are necessary, meticulous daily care is required. The tubing should never be placed higher than the bladder to prevent any backflow of urine into the bladder.
types of catheters
External, Straight, Retention
odor
Faintly aromatic abnormal: Foul=Infection Strong=Dehydration Pungent=Certain foods
urinary diversions
In a urinary diversion, one or both ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. The ureters may be brought to and through the skin of the abdomen (Fig. 30-14) or implanted within the bowel (called an ileal conduit). A urostomy (a urinary diversion that discharges urine from an opening on the abdomen) is the focus of this discussion. Urine drains continuously from a urostomy, increasing the risk for skin breakdown. In addition, because moisture and the weight of the collected urine tend to loosen the appliance from the skin, a urinary appliance may need to be emptied and changed more frequently. When changing the appliance, it may help to place a tampon within the stoma to absorb urine temporarily while the skin is cleansed and prepared for another appliance.
incontinence
Incontinence means the inability to control either urinary or bowel elimination and is abnormal after a person has achieved earlier continence. The term urinary incontinence should not be used indiscriminately: anyone may be incontinent if his or her need for assistance goes unnoticed. Once the bladder becomes extremely distended, spontaneous urination may be more of a personnel problem than a client problem. (The client may not be incontinent if staff members are attentive to his or her need to urinate.)
Nursing assesment
Inquire about the number of voidings per day; voiding more than eight times in 24 hours or waking up two or more times at night to urinate, or urinating soon after the bladder has been emptied suggests a pattern of urgency or what has also been referred to as an overactive bladder. Identify the interim the client can wait to postpone urination following the sensation of a need to empty the bladder, commonly referred to as warning time (Carpenito, 2013). Ask the client if the need to urinate is less easily controlled as the person gets nearer to the location of a toilet. Determine if the client experiences accidental loss of urine when there is an almost unstoppable need to urinate.
color
Light yellow abnormal: Dark amber=Dehydration Brown=Liver/gallbladder disease Reddish-brown=Blood Orange, green, blue=Water-soluble dyes
gerontologic considerations
Loss of control over urination often threatens an older adult's independence and self-esteem. It also may cause an older adult to restrict activities, possibly contributing to depression. Teaching older adults to structure activities with planned toileting breaks every 60 to 90 minutes results in less urine in the bladder and thus diminishes urge incontinence. Older adults who experience difficulty controlling urine need an evaluation to identify and treat contributing factors, such as constipation, urinary tract infection, and side effects from medications. Older adults need encouragement to discuss urinary incontinence with a knowledgeable, nonjudgmental health care provider. If they understand that urinary incontinence is a condition that frequently responds to medication or behavioral retraining, they are more likely to seek professional help. Many resources are available to assist older adults in evaluating and treating incontinence. For example, some health care facilities offer special incontinence clinics and physical therapy departments to teach pelvic muscle exercises. The National Association for Continence is an excellent source of information for products, resources, and continence programs. Nurses can encourage older adults to take advantage of these kinds of resources rather than accepting incontinence as an inevitable condition that compromises their quality of life. When efforts to restore continence are unsuccessful, nurses can encourage older adults to verbalize their feelings and identify interventions helpful in maintaining dignity, ultimately enabling older adults to participate in meaningful activities.
total
Loss of urine without any identifiable pattern or warning ex. The person passes urine without any ability or effort to control. cause: Altered consciousness secondary to a head injury, loss of sphincter tone secondary to prostatectomy, anatomic leak through a urethral/vaginal fistula nursing approach: Absorbent undergarments External catheter Indwelling catheter
urge
Need to void perceived frequently, with short-lived ability to sustain control of the flow ex. Voiding commences when there is a delay in accessing a toilet. cause: Bladder irritation secondary to infection; loss of bladder tone from recent continuous drainage with an indwelling catheter nursing approach: Restriction of fluid intake of at least 2,000 mL/day Omit bladder irritants, such as caffeine or alcohol. Administration of diuretics in the morning
Gerontologic considerations
Older adults are likely to experience urinary urgency and frequency because of normal physiologic changes such as diminished bladder capacity and degenerative changes in the cerebral cortex. Subsequently, when they perceive the urge to void, they need to access a bathroom as soon as possible. Age-related changes, such as a diminished bladder capacity and a relaxation of the pelvic floor muscle tone, increase the risk for incontinence. Fluid restriction may be used in an attempt to control urination, but it may actually contribute to incontinence by causing concentrated urine and eliminating the normal perception of a full bladder.
Gerontologic Considerations
Older adults are more likely to have chronic residual urine (excessive urine in the bladder after urinating), which increases the risk for urinary tract infections. Maintenance of good perineal hygiene is one intervention for preventing urinary tract infections. Women should always clean from the urinary area back toward the rectal area to prevent organisms from the stool entering the bladder. In addition, thorough hand washing by the client and caregiver is necessary. Also, older adults may benefit from learning double-voiding in which the person voids, then waits a few more minutes to allow any residual urine to be voided (American Urological Association, 2014).
24 hour specimens
The nurse collects, labels, and delivers a 24-hour specimen (a collection of all urine produced in a full 24-hour period) to the laboratory for analysis. Because the contents in urine decompose over time, the nurse places the collected urine in a container with a chemical preservative or puts the container in a basin of ice or in a specimen-dedicated refrigerator. To establish the 24-hour collection period accurately, the nurse instructs the client to urinate just before starting the test and then discards that urine. All urine voided thereafter becomes part of the collected specimen. Exactly 24 hours later, the nurse asks the client to void one last time to complete the test collection. The final urination and all collected voidings from the preceding 24 hours represent the total specimen, which the nurse labels and takes to the laboratory.
instructions
The nurse teaches the female client as follows: Wash your hands. Remove the lid from the specimen container. Rest the lid upside down on its outer surface, taking care not to touch the inside areas. Sit on the toilet and spread your legs. Separate your labia with your fingers. Cleanse each side of the urinary meatus with a separate swab, wiping from front to back toward the vagina. Use the final clean, moistened swab to wipe directly down the center of the separated tissue. Begin to urinate. After releasing a small amount of urine into the toilet, catch a sample of urine in the specimen container. Take care not to touch the mouth of the specimen container to your skin. Place the specimen container nearby on a flat surface. Release your fingers and continue voiding normally. Wash your hands. Cover the specimen container with the lid. The male client should follow the same steps as above but should perform the following cleansing routine: Retract your foreskin, if you are uncircumcised, or cleanse in a circular direction around the tip of the penis toward its base using a premoistened swab. Repeat with another swab. Continue retracting the foreskin while initiating the first release of urine and until you have collected the midstream specimen.
characteristics of urine
The physical characteristics of urine include its volume, color, clarity, and odor. Variations in what is considered normal are wide
catheter associated urinary tract infections
Those who are catheterized are at risk for acquiring urinary tract infections. The Centers for Disease Control and Prevention (CDC, 2015) estimates that 75% of all urinary tract infections are acquired by those with indwelling catheters, especially those that are in place for a prolonged period of time. In an effort to prevent catheter-associated urinary tract infections (CAUTI), the American Nurses Association (2015) has recommended measures to reduce their incidence: Advocate against inappropriate short-term catheter use. Secure the catheter appropriately. Keep the drainage bag below the level of the bladder at all times. Empty the drainage bag regularly. Keep the catheter and drainage tube from kinking. Maintain a closed drainage system. Perform perineal hygiene at least daily. Remove urinary catheters in a timely fashion. Provide rigorous catheter care.
Kegel exercises
Tighten the internal muscles used to prevent urination or interrupt urination once it has begun. Keep the muscles contracted for at least 10 seconds. Relax the muscles for the same period. Repeat the pattern of contraction and relaxation 10 to 25 times. Perform the exercise regimen three or four times a day for 2 weeks to 1 month.
clarity
Transparent
managing incontinence
Urinary incontinence, depending on its type, may be permanent or temporary. The six types of urinary incontinence are stress, urge, reflex, functional, total, and overflow
overflow
Urine leakage because the bladder is not completely emptied; bladder distended with retained urine ex. The person voids small amounts frequently, or urine leaks around a catheter. cause: Overstretched bladder or weakened muscle tone secondary to obstruction of the urethra by debris within a catheter, an enlarged prostate, distended bowel, or postoperative bladder spasms nursing approach: Hydration Adequate bowel elimination Patency of catheter Credé maneuver
polyuria
greater-than-normal urinary elimination and may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (eg, coffee and tea), or taking certain medications actually can increase urination. Ordinarily, urine output is nearly equal to fluid intake. When the cause of polyuria is not apparent, excessive urination may be the result of a disorder. Common disorders associated with polyuria include diabetes mellitus, an endocrine disorder caused by insufficient insulin or insulin resistance, and diabetes insipidus, an endocrine disease caused by insufficient antidiuretic hormone.
voided specimen
is a sample of fresh urine collected in a clean container. The first voided specimen of the day is preferred because it is most likely to contain substantial urinary components that have accumulated during the night. Nevertheless, the specimen can be voided and collected at any time it is needed. The sample of urine is transferred into a specimen container and delivered to the laboratory for testing and analysis. If the specimen cannot be examined in less than 1 hour after collection, it is labeled and refrigerated.
clean-catch specimens
is a voided sample of urine considered sterile and is sometimes called a midstream specimen because of the way it is collected. To avoid contaminating the voided sample with microorganisms or substances other than those in the urine, the external structures through which urine passes (the urinary meatus, which is the opening to the urethra, and the surrounding tissues) are cleansed. The urine is collected after the initial stream has been released. Clean-catch specimens are preferred to randomly voided specimens. As soon as the specimen is collected, it is labeled and taken to the laboratory. A clean-catch urine specimen is refrigerated if the analysis will be delayed more than 1 hour.
dysuria
is the difficult or uncomfortable voiding and a common symptom of trauma to the urethra or a bladder infection. Frequency (the need to urinate often) and urgency (a strong feeling that urine must be eliminated quickly) often accompany dysuria.
nocturia
is unusual because the rate of urine production is normally reduced at night. Consequently, nocturia suggests an underlying medical problem. In aging men, an enlarging prostate gland, which encircles the urethra, interferes with complete bladder emptying. As a result, there is a need to urinate more frequently, including during the usual hours of sleep.
Anuria
means the absence of urine or a volume of 100 mL or less in 24 hours. It indicates that the kidneys are not forming sufficient urine. In this case, the term "urinary suppression" is used. In urinary suppression, the bladder is empty; therefore, the client feels no urge to urinate. This distinguishes anuria from urinary retention, in which the client produces urine but does not release it from the bladder. A sign of urinary retention is a progressively distending bladder.
