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MEASURES TO PROMOTE URINARY ELIMINATION FLUID INTAKE AND OUTPUT MONITORING

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It refers to the measurement of all fluids that enter and exit the body. Intake- Includes all the food and fluids that are liquid at room temperature(such as ice cream gelatine, etc.), parenteral fluids, and any other fluids taken into the body. Output-includes urine, vomitus, diarrhea, drainage from suctioning devices, and other fluids that come out from the body.

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Purpose:
monitor the patients fluid intake, output and renal functions.
To

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Procedure:
Gather equipment,(I and O sheet, pencil, calibrated glass, bedpan/ urinal) Indicate in the nursing care plan that the patient is on I and O orders, and post a sign stating Intake and Output on his room door or near the bed. Keep the I and O sheet in the client's room. Explain to the patient or family members that the record is being kept of fluid intake and output and explain that they can participate by monitoring these when the nurse is not in the room.

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Monitoring, measure and record all fluids that enter the patients body, including IV, feeding, blood and oral during and between meals. Monitor, measure and record all fluids that leave the patients body, including from indwelling catheter, fluids from nasogastric tube, wound drains, vomitus and liquid stool, etc. Perspiration and blood loss may be described as scanty, moderate, profuse or excessive. For in-patient with cystoclysis and peritoneal dialysis, subtract the amount infused from the total output in every shift. The difference is considered the urine output and is recorded in the I and O sheet.
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URINE CATHETERIZATION
It

is the introduction of a sterile catheter into the bladder from the urinary meatus for the purpose of withdrawing urine.

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Catheterization is indicated in the following situations :

1. For immediate relief of bladder distention a. Patients an able to void 8-12 hours following surgery. b. Patients with acute retention following trauma to the urethra. c. Patients unable to void as a result of the effects of sedative and analgesic. 2. for long-term management of client with incompetent bladder. a. Spinal cord injuries b. Progressive neuromuscular degeneration 3. To obtain sterile urine specimen.
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4.To assess for the presence of residual urine voiding Measuring the PVR ( postvoid residual: the amount of urine remaining in the bladder immediately after urination. Normal > less than 50 ml---------indicates adequate bladder emptying. > more than 200 ml -----indicates inadequate bladder emptying. > between range---------indicates further evaluation. > 300ml -------------------immediate catheterization to bladder distension. 5. When there is an obstruction to urine outflow

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6. For patients undergoing surgical repair of the urethra and surrounding structures ( TUR) 7. To prevent urethral obstruction from the blood clots 8. To provide means of recording output measurement in critically ill or comatose patients. 9. To prevent skin breakdown in comatose patients who are incontinent. 10. To provide continuous bladder irrigation
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Types
1. Indwelling Catheter: to remain in place for continuous drainage.

Purpose:
Gradual decompression of an overdistended bladder For intermittent bladder drainage and irrigation Form continuous bladder drainage. 2. Intermittent catheters (straight catheters)

Purpose:
Used to drain bladder for shorter period of time (510 minutes)
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3.Suprapubic Catheter

Purpose:
Occasionally used for continuous drainage. Diverts urine from the urethra when injury, stricture, prostatic obstruction or gynaecologic or abdominal surgery that has compromised the flow of urine through the urethra.
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Equipment:
a. Catheterization tray which contains the following: - Sterile gloves - Sterile forceps - Sterile cotton balls - Lubricant (K-Y Jelly) - Antiseptic cleansing solution ( betadine solution ) - Straight or indwelling catheter - Prefilled syringe (10-20ml) with distilled water to inflate the balloon for indwelling catheter b. sterile drainage tubing and collection bag c. tape, rubber band, safety pin, toilet paper d. flashlight or gooseneck lamp (for female patient) e. receptacle or basin

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Procedure:
1. Check the doctors order. 2. Gather the equipment 3. Wash your hands 4. Prepare the patient a. Explain procedure and rationale b. Provide opportunity to ask questions c. Provide privacy by closing the curtains or door
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d. Position the patient FEMALE: Dorsal recumbent position with the knees flexed and the feet about 2 ft. apart or, if preferred, the patient can be placed inside lying position ( Sims position). e. Drape the patient f. Arrange lighting to visualize the meatus clearly g. Do the perineal flushings to decrease the possibilities of introducing organisms into the bladder.
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5. Prepare the urine drainage set- up if indwelling catheter is to be used, and secure it at the bed frame. 6. Set- up other equipment on over bed table or at the foot part of the bed. 7. Open the sterile gloves and get the outer wrapper. Unfold the outer wrapper and put it under the patients buttocks.
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8. Using the solution tray for catheterization clean the meatus by: Female: Using cotton ball held with forceps, cleanse both labia folds then the meatus. Down toward the rectum, using a single stroke. Male: Clean in a circular motion, starting at the meatus without retracing any area. 9. Open the package of the catheter (straight catheter or indwelling), then apply a lubricant ( K-Y jelly ) at the tip, keeping it sterile.

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10. Put on the gloves, and then grasp the catheter with your dominant hand. Using your non dominant hand, expose the meatus. 11. Insert the catheter. Once there is urine outflow, advance the catheter another inch to 1 inch farther. Female: 2 to 3 inches Male: 6 to 9 inches 12. Hold the catheter securely with the non dominant hand while the bladder empties. Collect specimen if required.

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13. Remove the catheter smoothly and slowly if a straight catheterization was ordered. 14. For indwelling catheter: a. Inflate the balloon using the prefilled syringe. Use the amount of fluid indicated on the catheter itself plus 4 to 5 ml. b. Check for security by gently pulling the catheter until the resistant is felt. 15. Attach the catheter to the drainage tubing
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16. Secure the catheter to the patient by applying tape. Female: Inner aspect of the thigh Male: To the side of lower abdomen 17. Attach tubing to bed using tape or safety pin. 18. Make the patient comfortable - cleanse and dry the perinial area using wet towel or tissue paper
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19. Care of the equipment used 20. Wash your hands 21. Record the time or the catheterization, the amount of the urine removed, a description of the urine and patients response to the procedure.

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CARE OF THE PATIENTS WITH INDWELLING CATHETER

The

urinary tract is usually sterile. The introduction of organisms via the catheter is a common of UTI.

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A variety of measures are used to decrease the risk of infection:

a. Place the patient on I and O recording. b. Encourage the patient to consume increased quantities of fluid if not contraindicated.

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c. Maintain external cleanliness around the catheter. Secretions that build up are optimum location for bacterial growth. C.1 Do perineal flushing twice a day and after each BM C.2 Clean the meatal area with antibacterial solution and apply an antimicrobial ointment at the meatus around the catheter. Be sure to ask the patient any about the allergy to the solution and to the ointment to be applied. d. Keep the catheter drainage bag below the level of the bladder at all times .

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d. Keep the catheter drainage bag below the level of the bladder at all times e. Keep the drainage bag at the floor f. Take the catheter in a way that avoids pulling it. g. Take extra care when moving or ambulating a patient, you must watch the position of the tubing and bag at all times to prevent pulling.
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h. Empty the bag at regular intervals or as necessary i. Observe for irritation at meatal area. Report to the physician, if you find any j. Maintained a closed system at all times.

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INDWELLING CATHETER REMOVAL

The

indwelling catheter removal and the after care of the patient should include the following nursing measures:

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Procedure
1. Verify orders 2. Obtain a necessary equipment a. used syringe ( 10 cc- 20 cc ) b. tissue paper 3. Explain the procedure to the patients 4. Position the patients

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5. Discontinue the catheter: a. Placed paper towels under the catheters b. Aspirate the fluid from the balloon using a syringe c. Have the patient take several deep breaths. Pinch the catheter and pull it out smoothly. d. Wrap the end of the catheter in paper towel and dispose properly. 6. Make the patient comfortable

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7. Dispose properly the equipment after measuring the output 8. Continue with the intake and output for at least 24 hours. 9. Record the time of catheter removal, output, patients response to the nurses notes. 10. Endorsed the voiding due time of the patient.
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EXTERNAL CATHETERIZATION ( USE OF CONDOM CATHETER )

When

voluntary control of urination is not possible for male patients, and alternative to an indwelling catheter is the condom catheter. This is a soft and pliable plastic of rubberized material device that is applied externally to the patients.
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Nursing Consideration:
1. The condom catheter should be removed daily and the penis should be washed with soap and water, carefully dried, and inspected for irritation. 2. Care must be taken to fasten the condom catheter securely enough to prevent leakage yet not so tightly as to constrict the blood vessels in the area. 3. Te tip of the tubing should be kept 2.5 cm to 5 cm beyond the tip of the penis to prevent irritation to the sensitive glands.
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4. To prevent urine from excoriating the glands, the tubing collecting urine from the condom should be positioned to draw urine away from the penis.

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Equipment:
condom

sheath in appropriate size with strap disposal gloves urinary drainage set-up basin of warm and soap washcloth and towel

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Procedure:
1. Explain the procedure to the patient. 2. Assemble equipment 3. Prepare urinary se-up for attachment to the condom catheter. 4. Wash your hands.

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5. Assist the patient to supine position, close the certain door. Use the top sheet as drape, expose only the patients genital area. 6. Don disposable gloves, wash the genital area with soap and water. Rinse, and dry thoroughly 7. Roll the condom sheath outward onto itself. Grasp the penis firmly with your non-dominant hand. Apply the condom sheath by rolling it onto the penis with your dominant hand, leave 2.5 to 5 cm. Space between the tip of the penis and the end of the condom sheath.

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8. Apply the elastic or Velcro strap snugly but not tightly. Dont allow the elastic strap to come in contact with the skin. 9. Connect the equipment. Place the patient in a comfortable, safe position. Wash hands. 10. Remove the equipment. Place the patient in a comfortable, safe position. Wash your hands. 11. Assess the patients response and record observations on the patients chart.
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CATHETER IRRIGATION
The

flushing of a tube, canal, or area with solution is called irrigation. The purpose of the catheter irrigation is to restore or maintain its patency.

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A. Irrigating the Catheter using the Closed System

provides

intermittent or continuous irrigation without disconnecting the catheter from its drainage system; it is used for patient at risk for occlusion of the catheter with blood clots and mucus fragments after genitourinary surgery.
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Equipment:
sterile

basin cotton balls with disinfectant or alcohol swabs 30-50 ml. syringe with 18-gauge needle sterile irrigating solution drape
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Procedure1: Closed System

1. Assemble equipment, wash your hands. Explain the procedure and its purpose to the patient. 2. Provide privacy by closing the curtain s or door and drape the patient with blanket. 3. Assist the patient to a comfortable position and expose the aspiration port on the catheter set-up. Place the drape (towel or tissue paper) under the catheters aspiration port.
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4. Open the sterile supplies. Pour sterile solution into the sterile basin. Aspirate irrigant (30ml-50ml ) into the sterile syringe and attach the capped sterile needle. 5. Disinfect the aspiration port with alcohol swab or with antiseptic solution. 6. Clamp or fold the catheter tubing distal to the aspiration port. 7. Remove the cap and insert the needle into the port. Gently instill solution into the catheter.
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7. Remove the cap and insert the needle into the port. Gently instill solution into the catheter. 8. Remove the needle from the port, unclamp the tubing and allow irrigant and urine to drain. Repeat the procedure as necessary. 9. Remove equipment and discard needle and syringe in appropriate receptacle. Wash your hands, and place patients back to a comfortable position. 10. Assess and document the patients response to the procedure and the quality and amount of drainage in the nurses notes. 11. Record the amount of irrigant used and the total drainage in the I and O sheet.

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B. Irrigating the catheter using the Open System

It is an alternative method, require that the nurse aseptically break the closed drainage system: this method is use intermittently to maintain catheters patency but should be done only when necessary because of the risk of introducing pathogens into the bladder
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Equipments:
Irrigation

tray Sterile Basin Sterile Aseptosyringe Sterile Irrigating solution Gauze Pad Cottonballs with disinfectants

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Procedure 2: Open System

1. Follows steps 1 and 2 and procedure for closed system. 2. Assist the client to a comfortable position and expose3 the connection between the catheter and the drainage tubing. Place a tissue paper under catheters connection port. 3. Open the sterile supply. Pour the sterile solution in the sterile basin. Aspirate irrigant (30 ml) into the asepto syringe.
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4. Cleanse the catheter junction using cottonballs with disinfectant. 5. Disinfect the catheter and drainage tube. Place the cover over the drainage tip and secure drainage tubing on the bed. Hold catheter tubing (2.5 cm )from its open end. 6. Position the sterile basin beneath the catheter. Insert the tip of the syringe into the catheter and gently irrigate with solution.
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7. Remove the syringe and allow drainage to return by gravity flow into the basin, if there is no return flow, gentle aspirate the solution from the catheter. Continue with irrigation as ordered by the physician. 8. Reattach the drainage tube to the catheter, beginning carefully not to contaminate the system. 9. Remove the equipments and place back the client in a comfortable position.Wash your hands 10. Document clients response to the procedure and the quality and the amount of drainage on the clients chart

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Cystoclysis

It is most frequently done after surgical procedure on the bladder. This is done to clean or medicate the bladder itself. The physician may order a specific flow rate in ml/hour or may simply order that is a slow continuous drip be used, or depending upon the character of the urine.
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Equipments:
Sterile

irrigating solution (2 liters bottle of PNSS) Sterile tubing (IV tubing) IV pole Foley drainage set-up (tubing and collection Bag) 3- way foley catheter in place.
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Procedure
1. Explain the procedure/ purpose to the client. 2. Assemble equipment. 3. Hand washing. 4. Provide privacy and drape the client.

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5. Prepare the sterile irrigation solution. (available in IV bottle). Attach the sterile tubing with drip chamber to the container.Hang the bottle on IV pole 2 to 3 ft. above the level of clients bladder. Release the clamp; remove the protective cover on the end of IV tubing without contaminating it. Allow the solution to flash the tubing and remove air. Reclamp or close the regulator. 6. Attach the irrigation tubing to the irrigation (usually on the third port) of the 3 way foley catheter using sterile technique. 7. Release the clamp on the irrigation tubing and regulate the flow according to the physicians order.
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7. Release the clamp on the irrigation tubing and regulate the flow according to the physicians order. 8. As irrigation is completed, clamp the tubing. Do not allow the drip chamber to empty. Disconnection of the empty and attach a full irrigation bottle. Continue as orders by the physician. 9. Assess the clients response to the procedure and the quality and amount of drainage. Empty the drainage collection bag as each new container is hang and record. 10. Wash your hands. 11. Record the amount of irritant used on the intake and output and record and subtract drainage collected to ensure accurate recording of urine output.

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Nursing Considerations:
1. Use aseptic technique when irrigating the bladder to prevent infection. 2. Review the physicians order for the type and amount of solution to be used and the type of irrigation to be performed. 3 Do not force irrigation against any resistance; Notify the physician. 4. Refer for signs of active bleeding by assessing the color of the drainage, presence of pain or tenderness over the hypogastrium. 5. If the flow slows down, assess for the patency of the tubing, check for kinks or milk the tubings to remove clots and refer to ROD if measures failed. Prepare equipment needed for flushing the catheter.

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