Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.

N MAN Clinical Instructor

NURSING SKILLS URINARY ELIMINATION Lecturer: Mark Fredderick R. Abejo RN MAN _____________________________________________

Urinary Catheterization
Purposes: To relieve bladder distention or to provide gradual decompression of a distended bladder To instill medication into the bladder To irrigate the bladder To measure hourly urine output accurately To collect urine specimen To measure residual urine Residual Urine, is the amount of urine retained in the bladder after forceful voiding To maintain continence among incontinent clients To prevent urine from contracting an incision after perineal surgery To promote healing of the genito-urinary structures postoperatively

Equipment: Catheter insertion kits: A, indwelling; B, straight.

Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Assessment Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total amount of urine to be removed or size of catheter to be used: Straight Catheter - use for a spot urine specimen - amount of residual urine is being measured - temporary decompression / emptying of the bladder is required. Indwelling/Retention Catheter - if the bladder must remain empty or continuous urine measurement and collection is needed Determine if the client is able to cooperate and hold still during the procedure and if the client can be positioned supine with head relatively flat. Determine when the client last voided or was last catheterized. Percuss the bladder to check for fullness or distention

appropriate position: Male: Supine, legs abducted and extended Female: Dorsal recumbent Don sterile gloves Inflate the balloon of catheter with air to check that it is intact then deflate. Locate the urinary meatus properly: Male: at the tip of the glans penis Female: between the clitoris and vaginal orifice

Steps / Procedure Verify doctors order Identify and inform the client and explain, why it is necessary and how he/she can cooperate Provide privacy Wash hands and observe appropriate infection control procedures Perform routine perineal care before the procedure Use appropriate size of catheter Male: Fr 16-18 Female: Fr 12-14 Have adequate lighting Place the client in

Rationale

To allay anxiety

To prevent feeling of embarrassment To prevent ascending UTI To minimize microorganism at the external genitals To prevent trauma to the mucous membrane To visualize urethral meatus properly

Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Cleanse urinary meatus with antiseptic solution Note: The nondominant hand is considered contaminated once it touches the client skin. Male: - Use your nondominant hand to grasp the penis just below the glans. - Hold the penis firmly upright with slight tension - Pick up a cleansing ball with the forceps and wipe from the center of the meatus in circular motion Note: The foreskin must not be allowed to return over the cleanse meatus nor the penis be dropped

Lifting the penis firmly and upright prevents possible erection and helps strengthen the urethra

the penis at 90 degree urethra and facilitate angle or insertion perpendicular to the body For indwelling or retention catheter, inflate the balloon with 5 10 ml. of PNSS Placement of indwelling / retention catheter and inflated balloon

Female: - Use your nondominant hand to spread the labia - Pick up a cleansing ball with the forceps in your dominant hand and wipe one side of the labia in an anteroposterior direction. - When cleansing the urinary meatus, move the swab downward Lubricate catheter with water soluble To prevent friction and lubricant before prevent trauma insertion Male: 6 7 inches Female: 1 2 inches Insert catheter gently in rotating motion. Instruct the client to take slow deep breaths to relax sphincter or strain as if attempting to void to opens urinary meatus Length of catheter insertion: Male: 6 9 inches Female: 3 -4 inches During insertion of catheter in male, hold To straighten the

Female

Male

Gently pull on the catheter. If resistance is felt, the catheter balloon is properly inflated in the bladder. Anchor catheter properly: Male: laterally or upward over the lower abdomen / upper thigh Female: inner aspect of the thigh Attach drainage bag to the bed frame, ensuring that tubing should fall below the top of the bag. Keep client comfortable Do after-care Do relevant documentation To prevent penoscrotal pressure

Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Elevate urine receptacle at the level of symphysis pubis to slow down expulsion of urine. Do not remove more than 1000 ml of urine at a time

Nursing Interventions for Client with Indwelling/Retention Catheter Practice asepsis. Proper handwashing should be done before and after manipulating the device. To prevent infection Increase fluid intake. To enhance excretion of microorganism and body wastes Acidify urine ( diet: meat,fish.eggs and cereals) Acidic urine inhibits proliferation of microorganism. Maintained closed drainage system. Do not detach catheter from the connecting tubing, unnecessarily. Meticulous perineal care. To prevent ascending UTI Note: If the purpose of catheterization is to relieve bladder distention, practice GRADUAL DECOMPRESSION, to prevent shock, hemorrhage or bladder atony. Gradual Decompression may be done by the following actions: Empty the bladder slowly by pinching the catheter to reduce the size of the lumen. Ensure patency of urinary catheter. Avoid kinks. Irrigate with sterile PNSS as ordered. Ensure that gravity drainage of urine is maintained. Hold the urinary drainage bag below the level of bladder when ambulating Monitor I & O Change urinary catheter, tubing and bag when sediments accumulates, if leakage is present or if a strong odor is evident.

STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Removal of Indwelling / Retention Catheter

Check doctors order Wash hands. Remove the tape that secured the catheter to the clients body Don clean disposable gloves. Handwashing and gloving prevent transfer of microorganism Insert hub of the syringe into balloon inflation port and draw out all the liquid. The balloon must be completely deflated to prevent trauma to the urethra as the catheter is remove. Instruct the client to inhale and then pinch and remove the catheter slowly and carefully as the clients exhales. Breathing provides distraction and exhalation prevents tightening of abdominal and perineal muscles as the catheter is withdraw. Pinching catheter prevents urine from dribbling onto the bed linens. After removal of catheter, allow the urine to drain into collection bag. Measure and record the amount of urine remaining in the collection bag. Assess clients perineum and meatus for any signs of redness or irritation. Assist client to do perineal care and dry genitals. To ensure client comfort. Discard contaminated equipment and articles in appropriate containers. To prevent contamination of the environment. Make relevant document NOTE: Voiding should be expected within 6 8 hours from the time of removal of catheter. Some dribbling of urine may be experienced. Continue to assess I & O If the client has not voided in 8 hours, assess for urinary retention If the client has difficulty establishing voluntary control of voiding, notify the physician. It may be necessary to reinsert the catheter or to perform in and out ( intermittent ) catheterization

STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Urinary Elimination
Characteristics of Normal and Abnormal Urine Characteristics
Amount in 24 hours

Normal
1, 200 1,500 ml ( 30 ml/hr)

Abnormal
Under 1,200 ml A large amount over intake

Nursing Considerations
Urinary output normally is approx. equal to fluid intake. Output of less than 30 ml/hr may indicate decrease blood flow to the kidneys and should be immediately reported Concentrated urine is darker in color Dilute urine may appear almost clear or very pale yellow. RBC in urine (hematuria) may be evident as pink, bright red or rusty brown urine WBC, bacteria,pus or contaminants such as prostatic fluid, sperm or vaginal discharge may cause cloudy urine. Note: Some drugs may alter urine color Rifampicin bright orange red Laxative red Chloroquine rusty yellow Phenazopyridine orange brown Some food (eg asparagus) cause a musty odor Infected urine can have a fetid odor. Urine high in glucose has a sweet odor Urine specimen may contaminate by bacteria from perineum during collection. Freshly voided urine is normally somewhat acidic. Alkaline urine may indicate a state of alkalosis, UTI or diet high in fruits and vegetables. More acidic urine (low pH) is found in starvation,diarrhea or with diet high in CHON Concentrated urine has a higher specific gravity. Diluted urine has a lower specific gravity Glucose in the urine indicates high blood glucose level (>180 mg/dl) and may be indicative of undiagnosed or uncontrolled DM Protein in the urine (proteinuria) may be indicative of PIH in pregnant women Ketones, the end product of the breakdown of fatty acids, are not normally present in the urine. They may be present in the urine of the clients who have uncontrolled DM or excessively ingest aspirin Pus in urine may indicative of UTI and other STDs Blood may be present in the urine of the clients who have UTI, kidney disease or bleeding from the urinary tract.

Color, clarity

Straw, Amber (Clear )

Dark Amber Cloudy Dark Orange Red/Dark Brown Mucous plugs, viscid,thick

Odor

Faint Aromatic

Offensive

Sterility pH

No Microorganism 4.5 8

Microorganism Present Over 8 Under 4.5

Specific Gravity Glucose

1.010 1.025 Absent

Over 1.025 Under 1.010 Present

Protein Ketones

Absent Absent

Present Present

Pus Blood

Absent Absent

Present Present

STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Alteration on Urinary Elimination Problem

Polyuria ( diuresis)

Definition

Selected Associated Factors

- Fluids containing caffeine or alcohol - Prescribed diuretics - Hx of DM. Diabetes Insipidus / K.Dse - Decrease fluid intake , dehydration - Hypotension, shock or kidney dse. - Decrease fluid intake , dehydration - Hypotension, shock or kidney dse. - Pregnacy - Increase fluid intake , UTI - Pregnacy - Increase fluid intake , UTI - Presence of physiologic stress - UTI - UTI, Infection and Trauma - UTI, Infection and Trauma - Family History, Home stresses - Difficult access to toilet facilities

Production of excessive amount of urine (> 100ml/hr or >2500 ml/day) Production of decreased amount of urine (<30ml/hr or <500ml/day) Absence of production of urine by the kidneys such as 0-10 ml/hr Voiding in frequent interval Increased urination at night The strong feeling that the person wants to void. Voiding that is either painful or difficult Difficulty in initiating voiding Bed wetting, repeated involuntary voiding beyond 4-5 years of age Frequent, scanty urination A continuous and unpredictable loss of urine Leakage of less than 50ml of urine as a sudden increase in entra abdominal pressure Follows a sudden strong desire to urinate and leads to involuntary detrusor contraction. Involuntary unpredictable passage of urine Involuntary loss of urine occurring at somewhat predictable intervals when specific bladder volume is reached The accumulation of urine in the bladder with associated inability of the bladder to empty itself. Note: 250-450 ml. of urine in the bladder triggers micturition reflex Clinical Signs of Urinary Retention: Discomfort in pubic area Bladder distention - smooth firm, ovoid mass at the supra pubic area - mass arising out of the pelvis - dullness on percussion Inability to void or frequent voiding of small volumes Increasing restlessness and feeling of need to void A disproportionately small amount of output in relation to fluid intake

Oliguria Anuria Urinary Frequency Nocturia Urinary Urgency Dysuria Hesitancy Enuresis Pollakuria Urinary Incontenence Total Incontenence Stress Incontenence

Urge Incontenence

Functional Incontenence Reflex Incontinence

- Bladder inflammation - UTI - Kidney diseases - Infections - Mobility impairment - Presence of physiologic stress - Cognitive impairment - Leakage when coughing, sneezing and laughing

Urinary Retention

- Recent anesthesia - Recent surgery - Presence of perineal sweeling - Medications prescribed - Lack of privacy - Difficult access to toilet facilities

STI Global City College of Nursing / QMMC Surgery Ward Exposure Lecture Notes on Urinary Elimination & Urinary Catheterization Prepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor

Nursing Interventions for Clients with Urinary Incontenence Bladder Retraining Program. Determine the clients voiding pattern or establish a regular voiding time. Lengthen the intervals of voiding once the clients voiding can be controlled. Regulate fluid intake Avoid large amounts of fruit juices and carbonated beverages. Avoid stimulants at bedtime Schedule diuretics in the morning. Adequate fluid intake in the morning. Kegels Exercise ( alternating tension and relaxation of the pubococcygeal muscles )

Nursing Interventions to Induce Voiding/Urination Provide privacy Provide fluids to drink Assist the patient in the anatomical position of voiding Serve clean, warm and dry bedpan (female) or urinal (male) Allow the client to listen to the sound of running water Dangle fingers in warm water Pour warm water over the perineum Promote relaxation Provide adequate time for voiding Perform Credes Maneuver as ordered ( this is done by applying pressure on the suprapubic area) Administer cholinergics as ordered Last resort: URINARY CATHETERIZATION