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  • 1. Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor NURSING SKILLS URINARY ELIMINATION Lecturer: Mark Fredderick R. Abejo RN MAN _____________________________________________ Urinary CatheterizationPurposes: 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 postoperativelyEquipment:Catheter insertion kits: A, indwelling; B, straight. A B
  • 2. Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical InstructorAssessment appropriate position: Determine the most appropriate method of Male: Supine, legs catheterization based on the purpose and any abducted and extended criteria specified in the order such as total Female: Dorsal amount of urine to be removed or size of recumbent catheter to be used: Don sterile gloves Inflate the balloon ofStraight Catheter catheter with air to- use for a spot urine specimen check that it is intact- amount of residual urine is being measured then deflate.- temporary decompression / emptying of the Locate the urinarybladder is required. meatus properly: Male: at the tip of theIndwelling/Retention Catheter glans penis- if the bladder must remain empty or continuous Female: between theurine measurement and collection is needed clitoris and vaginal orifice 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 Steps / Procedure Rationale Verify doctor’s order Identify and inform the client and explain, why it is To allay anxiety necessary and how he/she can cooperate Provide privacy To prevent feeling of embarrassment Wash hands and observe appropriate To prevent ascending infection control UTI procedures Perform routine To minimize perineal care before microorganism at the the procedure external genitals Use appropriate size of catheter To prevent trauma toMale: Fr 16-18 the mucous membraneFemale: Fr 12-14 Have adequate To visualize urethral lighting meatus properly Place the client in
  • 3. Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor Cleanse urinary meatus with antiseptic solution the penis at 90 degree urethra and facilitateNote: The nondominant hand is considered angle or insertioncontaminated once it touches the client skin. perpendicular to the bodyMale: For indwelling or- Use your nondominant hand retention catheter,to grasp the penis just below Lifting the penis inflate the balloonthe glans. firmly and with 5 – 10 ml. of- Hold the penis firmly upright prevents PNSSupright with slight tension possible erection- Pick up a cleansing ball with and helps Placement of indwelling / retention catheter andthe forceps and wipe from the strengthen the inflated ballooncenter of the meatus in urethracircular motionNote:The foreskin must not beallowed to return over thecleanse meatus nor the penisbe droppedFemale: Female Male- Use your nondominant handto spread the labia- Pick up a cleansing ball withthe forceps in your dominanthand and wipe one side of thelabia in an anteroposteriordirection. Gently pull on the- When cleansing the urinary catheter. If resistancemeatus, move the swab is felt, the catheterdownward balloon is properly Lubricate catheter inflated in the with water soluble bladder. lubricant before To prevent friction and Anchor catheter insertion prevent trauma properly:Male: 6 – 7 inchesFemale: 1 – 2 inches Male: laterally or To prevent penoscrotal Insert catheter gently upward over the lower pressure in rotating motion. abdomen / upper thigh Instruct the client to take slow deep Female: inner aspect of breaths to relax the thigh sphincter or strain as Attach drainage bag if attempting to void to the bed frame, to opens urinary ensuring that tubing meatus should fall below theLength of catheter top of the bag.insertion: Keep clientMale: 6 – 9 inches comfortableFemale: 3 -4 inches Do after-care During insertion of Do relevant catheter in male, hold To straighten the documentation
  • 4. Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared 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 UTINote: Ensure patency of urinary catheter. Avoid If the purpose of catheterization is to kinks. Irrigate with sterile PNSS as ordered.relieve bladder distention, practice GRADUALDECOMPRESSION, to prevent shock, Ensure that gravity drainage of urine ishemorrhage or bladder atony. maintained. Hold the urinary drainage bag below the level of bladder when ambulatingGradual Decompression may be done by the Monitor I & Ofollowing actions: Change urinary catheter, tubing and bag when Empty the bladder slowly by pinching the sediments accumulates, if leakage is present or catheter to reduce the size of the lumen. if a strong odor is evident.
  • 5. STI Global City College of Nursing / QMMC Surgery Ward Exposure 5Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical InstructorRemoval of Indwelling / Retention Catheter Check doctor’s order Wash hands. Remove the tape that secured the catheter to the client’s 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 client’s 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 documentNOTE: 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
  • 6. STI Global City College of Nursing / QMMC Surgery Ward Exposure 6Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical Instructor Urinary EliminationCharacteristics of Normal and Abnormal UrineCharacteristics Normal Abnormal Nursing Considerations Amount in 24 1, 200 – 1,500 ml Under 1,200 ml Urinary output normally is approx. equal to fluid hours ( 30 ml/hr) A large amount over intake. intake Output of less than 30 ml/hr may indicate decrease blood flow to the kidneys and should be immediately reported Color, clarity Straw, Amber Dark Amber Concentrated urine is darker in color (Clear ) Cloudy Dilute urine may appear almost clear or very pale Dark Orange yellow. Red/Dark Brown RBC in urine (hematuria) may be evident as pink, Mucous plugs, bright red or rusty brown urine viscid,thick 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 Odor Faint Aromatic Offensive Some food (eg asparagus) cause a musty odor Infected urine can have a fetid odor. Urine high in glucose has a sweet odor Sterility No Microorganism Urine specimen may contaminate by bacteria Microorganism Present from perineum during collection. pH 4.5 – 8 Over 8 Freshly voided urine is normally somewhat Under 4.5 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 CHONSpecific Gravity 1.010 – 1.025 Over 1.025 Concentrated urine has a higher specific gravity. Under 1.010 Diluted urine has a lower specific gravity Glucose Absent Present Glucose in the urine indicates high blood glucose level (>180 mg/dl) and may be indicative of undiagnosed or uncontrolled DM Protein Absent Present Protein in the urine (proteinuria) may be indicative of PIH in pregnant women Ketones Absent Present 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 Absent Present Pus in urine may indicative of UTI and other STD’s Blood Absent Present Blood may be present in the urine of the clients who have UTI, kidney disease or bleeding from the urinary tract.
  • 7. STI Global City College of Nursing / QMMC Surgery Ward Exposure 7Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical InstructorAlteration on Urinary Elimination Problem Definition Selected Associated FactorsPolyuria ( diuresis) Production of excessive amount of urine - Fluids containing caffeine or alcohol (> 100ml/hr or >2500 ml/day) - Prescribed diuretics - Hx of DM. Diabetes Insipidus / K.DseOliguria Production of decreased amount of urine - Decrease fluid intake , dehydration (<30ml/hr or <500ml/day) - Hypotension, shock or kidney dse.Anuria Absence of production of urine by the - Decrease fluid intake , dehydration kidneys such as 0-10 ml/hr - Hypotension, shock or kidney dse.Urinary Frequency Voiding in frequent interval - Pregnacy - Increase fluid intake , UTINocturia Increased urination at night - Pregnacy - Increase fluid intake , UTIUrinary Urgency The strong feeling that the person wants to - Presence of physiologic stress void. - UTIDysuria Voiding that is either painful or difficult - UTI, Infection and TraumaHesitancy Difficulty in initiating voiding - UTI, Infection and TraumaEnuresis Bed wetting, repeated involuntary voiding - Family History, Home stresses beyond 4-5 years of age - Difficult access to toilet facilitiesPollakuria Frequent, scanty urinationUrinary Incontenence Total Incontenence A continuous and unpredictable loss of - Bladder inflammation urine - UTI Stress Incontenence Leakage of less than 50ml of urine as a - Kidney diseases sudden increase in entra abdominal - Infections pressure - Mobility impairment Urge Incontenence Follows a sudden strong desire to urinate - Presence of physiologic stress and leads to involuntary detrusor - Cognitive impairment contraction. - Leakage when coughing, sneezing Functional Involuntary unpredictable passage of urine and laughing Incontenence Reflex Incontinence Involuntary loss of urine occurring at somewhat predictable intervals when specific bladder volume is reachedUrinary Retention The accumulation of urine in the bladder - Recent anesthesia with associated inability of the bladder to - Recent surgery empty itself. - Presence of perineal sweeling Note: - Medications prescribed 250-450 ml. of urine in the bladder triggers - Lack of privacy micturition reflex - Difficult access to toilet facilities 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
  • 8. STI Global City College of Nursing / QMMC Surgery Ward Exposure 8Lecture Notes on Urinary Elimination & Urinary CatheterizationPrepared By: Mark Fredderick R Abejo R.N MAN Clinical InstructorNursing Interventions for Clients with Urinary Incontenence Bladder Retraining Program. Determine the client’s voiding pattern or establish a regular voiding time. Lengthen the intervals of voiding once the client’s 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. Kegel’s 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 Crede’s Maneuver as ordered ( this is done by applying pressure on the suprapubic area) Administer cholinergics as ordered Last resort: URINARY CATHETERIZATION