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U 230 Adult Health 1

ALTERATIONS IN URINARY
ELIMINATION
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Class Outline Care of the Patient:


Undergoing diagnostic testing
With a lower urinary tract infection
With urinary incontinence
With urinary retention
With urolithiasis
Experiencing urinary diversions
Undergoing prostate surgery
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***Tables & Charts***


Think about:
Whos at risk?
Why & So What?
Preventive interventions
Assmt/Planning/Implementation/

Evaluation
Study Tables & Charts
3

Chapter 53
Assessment of Kidney and
Urinary Function

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Kidney and Urinary Systems


Regulates fluid and electrolytes, removing wastes and
providing hormones involved in red blood cell production,
bone metabolism, and control of blood pressure
Structures
Kidneys
Ureters
Bladder
Urethra

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Kidneys, Ureters, and Bladder

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Assessment (pgs.1514-1517)
Requires excellent communication skills
Risk factors
Chief complaint/Effect on quality of life
Symptoms
Pain (Table 53-2)
Changes in voiding (Table 53-3)
GI symptoms
Gero considerations (see p. 1513)
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Diagnostic Studies (pgs 1518-1524)


Urinalysis and urine
culture
Renal function tests:
refer to Table 53-5
Ultrasonography
CT and MRI
Nuclear scans
Endoscopic procedures

Biopsies
IV urography
Retrograde pyelography
Cystography
Renal angiography
Refer to Chart 53-4

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Urinalysis
Whats normal/what isnt/what
does it mean? - and then
what?
Color (Table 53-4)
Clarity & odor
Specific gravity (normal range 1.010-

1.025)
pH (nl @ 6)
Protein, glucose, ketone bodies, nitrites

Other Urine Tests


Urine for culture and sensitivity
Composite urine collections (24 hr)
Creatinine clearancebest

indication of overall kidney


function (approximation of GFR)
Urine osmolality (300-900
mOsm/kg/24h)

Lab Assessment of Renal


Function

Serum creatinine (will not increase


unless 50% of kidney function is lost)

BUN (can elevate from high protein


diet, tissue damage, infection, stress,
dehydration)

Serum creatinine more reliable

SC = 0.6-1.2 mg/dl

BUN = 7-18mg/dl
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Risks and Nursing Interventions in


Evaluations of Urinary System
All tests consider general principles

What position is needed?


Patient Education
Informed Consent if risk
Before and after care
Common nursing diagnoses/etiology: (Chart 53-4)
Deficient knowledge
Acute pain
Fear and anxiety

Special considerations
e.g. urodynamic testing, imaging, cystoscopy, biopsy
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Intravenous Urography
IVP Study
IVP= Intravenous Pyelography
What used for- assess gross kidney size or
obstruction
IV dye given then X-rays taken
Requires bowel prep so bowel contents will not
block picture
Normal to feel hot, flushed feeling when dye
injected
Not used as often secondary to multiple risks and
newer tests
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IVP
Risks and Nursing Interventions
Dye Studies Risks: Allergy, Nephrotoxic
Pre: assess iodine, contrast, shellfish
allergy, NPO to concentrate dye
Post: Monitor fever, wheeze, rash,
nausea, vomiting, rehydrate, monitor
renal function and I/O, serum Creat.,
may give acetylcysteine or IV sodium
bicarb to prevent renal damage
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Case
George Wright, 63 years of

age, is admitted in same day


surgery for a renal angiogram
for the diagnosis of renal
artery stenosis.

15

Questions
What patient education should

the nurse provide to the patient?


What preparation should the

nurse provide for the patient who


is going for a renal angiogram?

16

Renal Arteriography:
Catheter is inserted in femoral

artery at groin, to renal artery,


dye injected, x-ray pictures
Used to monitor for vascular

problems

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Renal Arteriography Risks and


Nursing Interventions
Risk: Bleeding: Prior to procedure monitor

PT/PTT,discontinue anticoagulants

Post: Pressure to catheter insertion site


Manual, ice and sand bag X 15 minutes
Bed-rest- 6 hours, then stand to void or

bedside commode x24hrs


Vital Sx q 15 minx4 etc,
H+H
Monitor for hematoma
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Arteriography Risks and


Interventions:
Risk: Embolus
Pre: Assess pulses, pedal pulses
Post: monitor for occlusion of femoral artery:

6 Ps, monitor distal pulses, notify MD

Risk: Infection : insertion of catheter / sterile

procedure
Post- temp q4hx48 to 72 h, monitor for
chills, malaise, WBC

Risk: renal failure secondary to dye

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Oscopy ( cystoscopy,
ureteroscopy)
Insertion of a scope into cavity to visualize or

treat.
Used for bladder wall problems or

obstructions
Interventions
NPO, laxative or fleets to remove stool from

the lower colon


Pain: Post: General or local anesthesia
Monitoring , mild discomfort
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Cystoscopic Examination

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Oscopy ( cystoscopy,
ureteroscopy
Infection-sterile procedure
Post- temp q4h -72h, monitor etc
Local trauma- assess bleeding- pink

tinged urine is normal, gross


hematuria is not, assess function
(leaking, retention)

If catheter in place- clots can obstruct

it. May need irrigation


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Biopsy- Insert needle into kidney


Used for unexplained renal problems or

renal CA dx

Pre- assess ability to lie +breathe in

prone, NPO
Pre- patient is sedated
Prone position 30-45 min
hold breath on request 15-30 seconds
Infection- sterile procedure -- same as
above
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Biopsy Risks
Post: Bleed Risk- BR, supine with back

roll( putting pressure on puncture site). At


least 6 hrs, then limited BRP if no bleeding
Can elevate HOB if back roll stays
monitor: VS, H+H, assess bleeding, pink
tinge ok, - no blood
monitor for hemorrhaging- pain, decr BP
Post - hematuria
Post- pain
Post- Infection- sterile procedure - same as
above
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Chapter 55
Management of Patients With
Urinary Disorders

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Why does this patient need a NURSE?

26

Case

Sue Meade, 22 years of age,


presents to the clinic with
complaints of burning, pain,
and urgency when urinating.
The patient has a fever of
100F. The urine is strong in
odor and cloudy with
sediments.
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Questions
a. What questions should the nurse
ask during the assessment to gain
more information about the
possible causes of the urinary
tract infection?
b. What patient education should
be provided?

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Urinary Tract Infections


Most common reason
health care
Common site of acquired
infection
Lower UTI

Upper UTI
Pyelonephritis: acute
and chronic
Interstitial nephritis
Renal abscess and
perirenal abscess

Cystitis
Prostatitis
Urethritis

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Factors Contributing to UTI


Function of glycosaminoglycan (GAG)
Urethrovesical reflux
Uretherovesical reflux
Uropathogenic bacteria
Shorter urethra in women
Risk factors

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Risk Factors for UTI (see Chart


55-2)
Incomplete bladder emptying
Obstruction
Immunosuppression
Instrumentation
Inflammation of urethra
Contributing conditions
e.g. DM, neurologic disorders
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Bladder Infection: Long-Term Catheterization

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Nursing Process: The Care of the Patient


With a UTIAssessment
Pain, burning upon urination, frequency, nocturia,
incontinence, hematuria
About half are asymptomatic
Association of symptoms with sexual intercourse,
contraceptive practices, and personal hygiene
Gerontologic considerations
Assessment of urine, urinalysis, and urine cultures
Other diagnostic tests

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Nursing Process: The Care of the Patient


With a UTIDiagnosis
Acute pain
Deficient knowledge
Predisposing factors: infection
Recurrence
Detection
Prevention
Pharmacologic therapy

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Collaborative Problems and Potential


Complications
Sepsis
Renal failure

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Nursing Process: The Care of the Patient


With a UTIPlanning
Major goals may include relief of pain and discomfort,
increased knowledge of preventive measures and
treatment modalities, and absence of complications.

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Interventions
Personal hygiene: wipe front to back
Medications as prescribed: antibiotics, analgesics, and
antispasmodics
Application of heat to the perineum to relieve pain and
spasm
Increased fluid intake
Avoidance of urinary tract irritants such as coffee, tea,
citrus, spices, cola, and alcohol
Frequent voiding
Patient education

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Question
Is the following statement true or false?
Older adult patients often lack the typical symptoms
of UTI and sepsis.

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Answer
True
Older adult patients often lack the typical symptoms
of UTI and sepsis.

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Urinary Incontinence
An underdiagnosed and underreported problem that can
have significant impact on the quality of life and decrease
independence, which may lead to compromise of the
upper urinary system
Urinary incontinence is not a normal consequence of
aging
Risk factors: refer to chart 55-6

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Urinary Incontinence/Assessment
History and observation
Physical
Psychosocial
UI in Hospitalized Older Adults
More than 25 million
35% admitted to hospital
What are risk factors and complications?
See consultgerirn.org reading
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Types of Urinary Incontinence


Stress
Urge
Reflex
Overflow
Functional
Iatrogenic
Mixed incontinence

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Urinary Incontinence/ stress


Nursing DX- stress incontinence
Leakage of <50ml with sudden increase in

abd pressure ( cough, sneeze, laugh, lift)


Mostly female

Cause: weakness of urethral and

surrounding pelvic muscles, childbirth


trauma, aging. Men after prostate surgery

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Stress Inc/ Management


Behavioral Therapy:
Pelvic muscle exercises (PME) - Chart 55-8
10-30 reps; 2-3x/day; 6 weeks
Voiding diary, biofeedback, PT
Weight loss if appropriate
Skin care

Meds as adjunct
anticholinergics, tricyclic antidepressants, (estrogen?)
Surgical management (see text pg- 1584)
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Urge Incontinence
Unable to suppress the urge to void
Involuntary
Causes: Neurogenic bladder (spastic and flaccid

bladder), uninhibited detrusor contraction

Behavioral Therapy (Chart 55-8)


Timed voiding, habit retraining, bladder

retraining
PME
Urge inhibition strategies

Meds as adjunct
Anticholinergics inhibit bladder contraction
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Incontinence contd..

Functional Incontinence
Results from non-urologic cause, from some physical, mental,
or environmental factor that prevents pts from reaching BR.
Treat underlying cause

Iatrogenic Incontinence

Involuntary loss of urine due to extrinsic medical factors


Medications (Example- Alpha adrenergic agents)

Incontinence resolves as soon as is discontinued

Mixed Urinary Incontinence

Involuntary leakage associated with urgency, exertion, effort,


sneezing, or coughing
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Total Incontinence
neurologic injury- s2-s4,

degenerative diseases , fistula


bladder to vagina, Cystectomy

Management- pads etc, prevent skin

breakdown, UTIs

Intravaginal pessary
Intravaginal balloon
Penile Clamp/ Condom cath
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Patient Education
Urinary incontinence is not inevitable and is treatable
Management takes time (provide encouragement and
support)
Develop and use a voiding log or diary
Behavioral interventions
Medication education related to pharmacologic therapy
Strategies for promoting continence

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Urinary Retention
Inability of the bladder to empty completely
Residual urine: amount of urine left in the bladder after
voiding
Causes include age (50100 mL in adults older than age
60 years caused by decreased detrusor muscle activity),
diabetes, prostate enlargement, pregnancy, neurologic
disorders, medications
Nursing measures to promote voiding: refer to Chart 559

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Retention
Definition- No normal urge to void

at 250-450ml
Inability to initiate voiding or
empty bladder completely

Symptoms: Distension d/t residual

urine

Can lead to overflow incontinence

or UTIs

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Retention
Causes: Medical conditions, post-op,

post-delivery, meds, obstruction,


neuro damage
Interventions- Treat cause if possible
Catheterization/ Intermittent/

Residual
Whats normal PVR?
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Retention
Bladder Training
Crede only if no outlet

obstruction
Valsalva
Double voiding technique

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Urolithiasis and Nephrolithiasis


Calculi (stones) in the urinary tract or kidney
Pathophysiology
Causes: may be unknown
Depend on location and presence of obstruction or
infection
Pain and hematuria
Diagnosis: radiography, blood chemistries, and stone
analysis; strain all urine and save stones

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Case study
John Lyons has undergone treatment for renal

stones three times in the last year. Today he calls


this primary health care provider with complaints of
acute, excruciating, colicky, pain that radiates down
the thigh toward the genitalia. The pain started last
night, and has become progressively more severe.
He also complains of the urge to void but has little
urine output, and it is blood tinged. Due to the pain,
he has not taken any fluids or food in 24 hours. Mr.
Lyons undergoes lithotripsy, and analysis of stone
fragments to reveal calcium stones.

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Questions
a. Mr. Lyons symptoms are most indicative of stones
in what area of the renal system?
Mr. Lyons has the following orders:
Morphine sulfate 2 mg IVP every 2 hours as

needed for severe pain


Ibuprofen 600 mg every 6 hours
Normal saline at 200 mL/hr
b. What are the rationales for the above orders?
c. Based on the calcium composition of the stone,
what dietary teaching should the nurse include in
Mr. Lyons plan of care? 55

Patient Education
Signs and symptoms to report
Follow-up care
Urine pH monitoring
Measures to prevent recurrent stones
Importance of fluid intake
Dietary education
Medication education as needed

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Genitourinary Trauma
Gunshot wounds = 95% of ureteral injuries
Pelvic fractures, blunt trauma
S/S classic triad: blood visible at the meatus, inability to
void, distended bladder

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Urinary Cancers
Bladder cancer more common after age 55 years
Men four times as often as women; 15,000 deaths
annually
Smoking increases risk 50%; refer to Chart 55-13
S/S: visible painless hematuria; pelvic or back pain may
indicate metastasis
Diagnosis: cystoscopy, CT, ultrasonography, biopsy
Treatment: surgery, fulguration, BCG regimen

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Urinary Diversion
Reasons: bladder cancer or other pelvic malignancies,
birth defects, trauma, strictures, neurogenic bladder,
chronic infection or intractable cystitis; used as a last
resort for incontinence
Cutaneous urinary diversion: ileal conduit, cutaneous
ureterostomy, vesicostomy, nephrostomy
Continent urinary diversion: Indiana pouch, Kock pouch,
uretherosigmoidostomy

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Nursing Diagnosis: Preoperative


Anxiety
Imbalanced nutrition
Deficient knowledge

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Nursing Diagnosis: Postoperative


Risk for impaired skin integrity
Acute pain
Disturbed body image
Potential for sexual dysfunction
Deficient knowledge

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Chapter 59
Assessment and Management of
Problems Related to Male
Reproductive Processes

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Assessment
Urinary function and symptoms
Sexual function and manifestations of sexual dysfunction
Symptoms related to urinary obstruction
Increased urinary frequency
Decreased force of stream
Double or triple voiding
Nocturia, dysuria, hematuria, hematospermia
Medications, drug, and alcohol use
Presence of conditions that may affect sexual function
(diabetes, cardiac disease, multiple sclerosis)
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Conditions of the Prostate


Prostatitis: inflammation caused by an infectious agent
Treatment includes appropriate anti-infective agents and
measures to alleviate pain and spasm
Benign prostatic hyperplasia (BPH; enlarged prostate)

Effects half of men older than age 50 years and 80% of


men older than age 80 years

Manifestations are those of urinary obstruction, urinary


retention, and urinary tract infections

Treatment
Pharmacologic: alpha-adrenergic blockers, alphaadrenergic antagonists, antiandrogen agents
Catheterization if unable to void
Prostate surgery
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Prostate Cancer
Second most common cancer and the second most common
cause of cancer death in men
Risk factors include increasing age, familial predisposition, and
African American race
Manifestations

Early disease has few or no symptoms

Symptoms of urinary obstruction, blood in urine or semen,


painful ejaculation

Symptoms of metastasis may be the first manifestations

Early diagnosis is vital; health screening


Treatment may include prostatectomy, radiation therapy,
hormonal therapy, or chemotherapy
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Nursing Process: The Care of the Patient


Undergoing ProstatectomyAssessment
Assess how the underlying disorder (BPH or prostate
cancer) has affected the patients lifestyle
Urinary and sexual function
Health history
Nutritional status
Activity level and abilities

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Nursing Process: The Care of the Patient


Undergoing Prostatectomy Diagnoses
Anxiety
Acute pain preoperatively
Acute pain postoperatively
Risk for imbalanced fluid volume postoperatively
Deficient knowledge

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Collaborative Problems and Potential


Complications
Hemorrhage and shock
Infection
Venous thromboembolism
Catheter obstruction
Complications with catheter removal
Urinary incontinence
Sexual dysfunction

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Nursing Process: The Care of the Patient


Undergoing ProstatectomyPlanning
Major goals before surgery include adequate preparation
and reduction of anxiety and pain.
Major goals after surgery include maintenance of fluid
volume balance, relief of pain and discomfort, ability to
perform self-care activities, and absence of
complications.

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Relief of Pain
Monitor urinary drainage and keep catheter patent
Assessment of pain
Bladder spasms cause feelings of pressure and
fullness, urgency to void, and bleeding from the
urethra around the catheter.
Medication and warm compresses or sitz baths to relieve
spasms
Administer analgesics and antispasmodics as needed
Encourage patient to walk but to avoid sitting for
prolonged periods.
Prevent constipation
Irrigate catheter as prescribed
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Three-Way System for Bladder Irrigation

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Interventions
Reduction of anxiety
Be sensitive to potentially embarrassing and
culturally charged issues
Establish a professional, trusting relationship
Provide privacy
Allow patient to verbalize concerns
Provide and reinforce information
Provide patient education, including explanations of
anatomy and function, diagnostic tests and surgery, and
the surgical experience.
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Rehabilitation and Home Care


Patient and family education for home care, including care of
urinary drainage devices and recognition and prevention of
complications
Regain bladder continence

Information that regaining control is a gradual process


(dribbling may continue for up to 1 year depending on
type of surgery)

Perineal exercises

Avoidance of straining, heavy lifting, long car trips (68 weeks)


Diet: encourage fluids and avoid coffee, alcohol, and spicy
foods
Assessment and referral of sexual issues
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Case Study
Joe Smith, a 55-year-old patient, is admitted to

the surgical unit after robotic-assisted


laparoscopic radical prostatectomy with nerve
sparring for early stage cancerous tumor
confined to the prostate. The client has six
small incisions in the abdomen with small 44
dressings with clear dressing dry and intact.
The client has a JP drain in place with clear, redcolored drainage with 50 mL present and an
indwelling urinary catheter draining clear, redcolored urine. The surgeon ordered ketorolac
(Toradol) for pain management and belladonna
74
and opiate (B&O) suppository
every 8 hours, as

Questions
What nursing care should be provided to the

patient in the immediate postoperative period?


For what potential complications should the nurse

observe, and what actions should the nurse take


if the complication develops?
The surgeon removes the JP drain the next day

and discharges the patient with the indwelling


urinary catheter to a leg bag. What discharge
instructions should the nurse provide the patient?
What follow-up care is anticipated for him?
75

What knowledge is needed?


Nursing is the protection, promotion, and
optimization of health and abilities,
prevention of illness and injury, alleviation
of suffering through the diagnosis and
treatment of human response, and
advocacy in the care of individuals,
families,
communities, and populations.

American Nurses' Association. (2003). Nursings social policy statement, 2nd edition.
Silver Spring, MD: Nursesbooks.org