1. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Chapter 31 Urinary Elimination and Care

2. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company

3. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinary System  Kidney—2  Ureters—2  Bladder  Urethra  Urinary meatus

4. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinary Conditions  Dysuria: painful or difficult urination  Nocturia: waking at night to urinate  Oliguria: urinary output less than 30 mL per hour  Polyuria: urinary output greater than 3,000 mL per day

5. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Normal Urinary Elimination  Urine  95% water  5% solutes  Dissolved in the water  Waste products resulting from cellular metabolism  Accumulate in blood

6. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinary Waste Products  Urea: results from amino acid metabolism  Uric acid: results from breakdown of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA)  Creatinine: the waste product of muscle metabolism

7. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Normal Urinary Elimination  Kidneys filter waste products from the blood  Eliminate in urine  Waste products, excess water, excess electrolytes, hydrogen ions that need to be eliminated, toxins, and other substances resulting from illness

8. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Normal Characteristics of Urine  Color: straw colored  Clarity: clear  Amount: 1,000 to 3,000 mL/day  Odor: mild; slightly aromatic  pH: 4.6 to 8.0  Specific gravity: 1.010 to l.025

9. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Color  Directly related to hydration level  Normally yellow  Darkens with decreased hydration

10. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Clarity  Normally clear  Cloudy (increased turbidity)  Presence of fat globules, red or white blood cells, or bacteria  Hematuria—blood present in urine—may be visible or microscopic

11. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Cloudy  Excessively alkaline—causing formation of crystals  Excessively acidic—causing formation of crystals  Sediment  Any substance that settles to the bottom of a liquid  Uric acid, bacteria, mucus, and phosphates

12. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Cloudy  Left sitting after the specimen is collected  Components in urine start to break down  If not going to be analyzed within 1 hour—should be refrigerated

13. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Amount  1,000 to 3,000 ml/24 hour  Acceptable minimal amount of urinary output per hour—30 ml  Volume of urine excreted (when fluids and electrolytes are balanced) should be within approximately 300 to 500 ml of total intake

14. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Oliguria  Urinary output of <30ml/hr  Causes—decreased fluid intake, dehydration, illness, urinary obstruction, renal failure, hemorrhage, or severe loss of body fluids (burns)

15. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Polyuria  Urinary output >3,000ml/day  Causes—excessive fluid intake, consumption of alcohol (affecting kidneys ability to reabsorb water), certain medications (diuretics)—Lasix and hydrocholorthiazide (HCTZ)  Monitor lab values—Lasix (K+), on a potassium supplement

16. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Anuria  Absence of urine or minimal urine production  Causes—result of temporary illness (vomiting and diarrhea due to a virus), urinary tract obstruction, or symptoms of serious underlying condition (kidney failure)  Dialysis—machine filters waste and removes excess fluid from blood

17. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Characteristics of Urine  Specific gravity  Result of comparing the weight of a substance with an equal amount of water  Normal specific gravity?  High specific gravity—urine more concentrated  Low specific gravity—urine more dilute

18. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Multiple Choice Question The nurse collecting a urine specimen from a patient knows that crystals may be in the urine due to which of the following? A. White blood cells B. Red blood cells C. Bacteria D. Increased pH

19. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Assessing Urine  Physical assessment  Color and clarity  Odor?  Volume  Edema?  Hands, legs, feet, sacrum, and face  Daily weight

20. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Assessing Urine  Frequency  Note any changes  Complaints?  Burning or difficulty starting stream  Dysuria—painful or difficult urination

21. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinalysis  Table 31-1  Color and appearance  pH  Specific gravity  Odor  Bacteria

22. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinalysis  Protein  Leukocyte esterase  Nitrites  Glucose  Ketones  White blood cells

23. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinalysis  White blood cell casts  Red blood cells  Red blood cells casts  Crystals

24. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Timed Urinary Collection  24 hour urine collection  All the urine produced within the 24 hour collection time must be collected in specimen jug  If only one void is skipped—the 24 hour collection must be restarted!

25. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Guidelines for 24 Hour Urine  Ask patient to void—discard urine—note time—starting time of urine collection  Patient starts test with an empty bladder  Post signs—24 hour urine in progress— bathrom  Keep container on ice or refrigerated

26. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Guidelines for 24 Hour Urine  If patient has indwelling catheter—place catheter collection bag in a basin of ice  24 hours after collection began—ask patient to void—add to collection container—test completed—send to lab—remove signs

27. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Clean-catch Midstream Urine  Do not touch inside of specimen container  Female—spread labia—cleanse front to back—three times—keep labia separated— begin to void in toilet—catch urine midstream—remove specimen cup—continue to void in toilet

28. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Clean-catch Midstream Urine  Male—retract foreskin if present—cleanse tip of penis from meatus outward until entire glans is cleansed—repeat three times—each time with new wipe—begin to void in toilet— catch urine midstream—remove specimen cup—continue to void in toilet  Specimen properly labeled—send to lab-- document

29. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Reagent Testing  Dipsticks  Immediate results  Must be read at specified times  Compare color changes on pads to chart on the side of dipstick container  Figure 31-2, pg. 716, Box 31-1, pg. 716

30. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Straining Urine  Renal calculi (kidney stones)  Can occur anywhere in urinary tract  Retain any placed stone  Send to lab for analysis  STRAIN ALL URINE

31. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Intake and Output  Measure fluid taken in  Measure fluid coming out  Assess for balance per shift and per 24 hr  Specimen pan, urinal—marked in mls.  Bedpan or bedside commode—empty into specimen pan—measure—avoid placing toilet tissue in with urine

32. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Alterations in Urinary Function  Bladder does not empty completely  Unable to initiate urinary stream  Urine released involuntarily  Blockages

33. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urinary Retention  Inability to empty bladder  Inability to completely empty the bladder  Acute or chronic  Normal function til reaches bladder  If not relieved—reflux to kidneys— hydronephrosis—renal damage

34. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Causes of Urinary Retention  Kidney stones  Enlarged prostate gland  Tumor  Pregnant uterus  Infection or scar tissue  Nerve disorders  Postoperative complications

35. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Residual Urine  Urine that remains in the bladder after voiding  Maximum amount of urine left in bladder after voiding 100 ml  Palpate bladder—just above symphysis pubis—distention?  Bladder scan—Figure 31-4

36. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Bladder Scan Demo  http://www.youtube.com/watch?v=1RobLmn hoVU&feature=related http://www.youtube.com/watch?v=1RobLmn hoVU&feature=related

37. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Nocturia  Awaken during the night to urinate  Excessive fluid intake  Rule out—congestive heart failure, uncontrolled diabetes mellitus, UTI, enlarged prostate, or kidney disease  Talk with your doctor

38. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Types of Incontinence  Stress—increased intra-abdominal pressure  Urge—overactive bladder  Overflow—obstruction  Functional—unable to reach a bathroom  Total—unaware of need to void  Neuropathic—nerve damage

39. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Stress Incontinence  Coughing, sneezing, laughing, heavy lifting…..  Vaginal births, surgery, genetics, hormones  Pelvic floor muscles become weak  increased intra-abdominal pressure

40. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Urge Incontinence  Inability to keep urine in the bladder to reach a bathroom--overactive bladder  Void more frequently  Hear water running, hands in warm water, drinking liquid  Bladder spasms

41. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Overflow Incontinence  Bladder distended--obstruction  Urine leaking past the obstruction

42. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Incontinence  Functional—inability to reach bathroom in time  Total—loss of urine with no warning  Neuropathic—nerve damage

43. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company True/False Question The nurse caring for patients in a long-term care setting knows that urinary incontinence is a normal part of the aging process. A. True B. False

44. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Managing Incontinence  Stress incontinence  Kegel exercises  Box 31-2, pg. 718  Tighten pelvic floor muscles  Hold contraction 5 to 10 seconds  Relax for 5 to 10 seconds  40 to 60 times throughout the day

45. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Initiating Bladder Training  Ensure adequate amount of fluids  Avoid caffeinated beverages  Drink more during a.m. and less in p.m.  Offer fluids throughout the day; avoid large volume at one time  Provide regular opportunities for toileting  Mimic patients’ normal voiding patterns

46. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Not a Candidate  Good skin care  Prevent breakdown  Change brief and perform perineal care q2h  Indwelling catheters are not used for incontinence  Can lead to UIT’s, sepsis, urethral strictures, prostatitis, and potential for bladder cancer

47. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Assisting Patients With Toileting  Offer opportunity to use bathroom/bedpan before and after meals and at bedtime  Allow male patients to void standing up if not contraindicated  Use a fracture pan for patients with hip or back surgeries  Provide privacy and avoid rushing  Offer hand hygiene after toileting

48. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Type of Catheters and Uses  Straight (single lumen)  One-time drainage or sterile specimen  Indwelling (double lumen or Foley)  Urine drainage for a specified amount of time  Three-way (triple lumen or Alcock)  Transurethral resection  Condom (Texas)  Male urinary incontinence

49. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Care of the Urinary Drainage Bag  Empty every 8 hours and document amount  Do not touch drainage spout to any surface and wipe with alcohol before closing  Always empty urine in a graduate to measure it  Maintain bag below the level of the bladder  Keep tubing free of kinks and coils  Hang on bed; do not rest on floor

50. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Catheter Care  At least once a shift  Anytime catheter is contaminated by a BM  Soap and water  Cleanse perineum  From insertion site down catheter  Do not pull or tug on catheter

51. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Multiple Choice Question A nurse prepares a patient for the procedure to obtain a sterile urine sample. Which of the following catheters would be used? A. Straight B. Indwelling C. Suprapubic D. Condom

52. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Read…………….  Skill 31-1, pg. 731  Skill 31-2, pg. 731-732  Skill 31-1, pg. 732-733  Skill 31-8, pg. 740

53. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Skill 31-1 Urinal  Check activity level  Prefer standing or sitting  Need assistance?  Gather supplies  Place urinal between legs—place penis inside the urinal

54. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Skill 31-1 Urinal  When finished—offer hand hygiene  Measure amount, assess color, clarity, odor  How was urinary stream?  Any burning, discomfort, difficultly starting, during, or at end?  Empty urinal, rinse, return to appropriate location—I&O if needed

55. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Skill 31-2 Bedpan  Review activity level  What type of bedpan?  Gather supplies  Clean gloves  Roll patient to one side—place bedpan firmly against the buttocks—assist patient to roll onto back and bedpan

56. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Skill 31-2 Bedpan  Fracture pan—patient may be able to raise hips and not have to turn—trapeze and lift up—place fracture pan  Raise head of bed (HOB) unless contraindicated  If patient able—provide privacy and supplies and call bell

57. Fundamentals of Nursing Care: Concepts, Connections, & Skills Copyright © 2011 F.A. Davis Company Skill 31-2 Bedpan  If on I&O—no toilet paper in bedpan  Carefully support bedpan—to prevent spilling—have patient lift up or turn on side to remove bedpan  Offer hand hygiene  Provide perineal care if needed  Clean bedpan—remove gloves—wash hands